Substance Abuse & Mental Health Services Administration

CMHS Consumer Affairs E-News
December 14, 2004 , Vol. 04-113

The American Psychiatric Association (APA) 2005 Annual Convention
May 21-26, 2005

Conference information available at: http://www.psych.org/edu/ann_mtgs/am/05/index.cfm

Application for Financial Support Application deadline: February 25, 2005

The Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (SAMHSA), through a contract with Westat/Health Systems Research, Inc. (HSR), is providing financial support to consumers of mental health services who wish to participate in the annual convention sponsored by the American Psychological Association. The purpose of the scholarships is to foster transformation of mental health care. Please note: the completed application and letter of recommendation must be received by February 25, 2005 in order to be eligible for this scholarship.

Contact Information:

NAME:
ORGANIZATION: ADDRESS:
CITY: STATE: ZIP:
PHONE: FAX:
E-MAIL:

Demographic Information:
Please provide the following optional information to help insure diversity of scholarship recipients.

Gender: Male Female Age: 18-25 26-55 56+

Ethnicity: Asian/Pacific Islander American Indian Black Hispanic White Other

Sexual Orientation: Heterosexual Gay Lesbian Bisexual

Physical Disability: Yes No

Are you a U.S. citizen? Yes No

Financial Support:
What type of scholarship support are you seeking (please check all that apply)?

Registration fee Hotel expense Per diem

Ground transportation Travel costs (please choose one from below)
airfare train mileage for car

Additional Information:
On a separate piece of paper, please provide the review committee with the following information:

1. What are the reasons you wish to attend the conference?
2. How you will disseminate information obtained at this conference to local or statewide consumer groups?
3. What are the specific issues relating to mental health in which you are most interested?
4. Are you currently involved with any related programs and activities? If yes, please describe.

Please provide at least one letter of recommendation with your completed application.

Scholarship Conditions:
Please note that in order to be eligible for this scholarship you must be a U.S. citizen and a mental health consumer. If you are selected as a scholarship recipient, a representative of HSR will contact you by April 8, 2005 to discuss travel arrangements. As a scholarship recipient, you will be asked to do the following:

1. Submit a 2 to 5 page report to HSR within 2 weeks of the conclusion of the conference in a format provided by HSR.
2. Submit an evaluation form to HSR within 2 weeks of the conclusion of the conference in a format provided by HSR.
3. Submit a travel reimbursement form to HSR within 2 weeks of the conclusion of the conference.
4. Inform HSR if you are unable to attend the conference or will be delayed in meeting the other three conditions.

Your signature below indicates that you have read and agree with the terms above.

Signature Date

Completed applications and letter(s) of recommendation must be received by February 25, 2005.

Please submit to: Stephanie Hauser

Health Systems Research, Inc.
1200 18th Street, NW, Suite 700
Washington, DC 20036
Phone: (202) 828-5100
Fax: (202) 728-9469
E-mail: shauser@hsrnet.com
Pager: (800) 619-4175

(Please leave your phone number including area code and we will return your call as soon as possible.)

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he Center for Mental Health Services is a component of the Substance Abuse and Mental Health Services Administration, United States Department of Health and Human Services.