Substance Abuse & Mental Health Services Administration

CMHS Consumer Affairs E-News
December 21, 2004, Vol. 04-116

NMHA 2005 ANNUAL CONFERENCE

The National Mental Health Association (NMHA) 2005 Annual Conference Hyatt Regency Washington on Capitol Hill, Washington, DC June 9 - 11, 2005

Conference information available at: 1-800-969-6642 or nmha.org

Application for Financial Support Application deadline: March 18, 2005

The Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (SAMHSA), through a contract with WestatlHealth Systems Research, Inc. (HSR), is providing financial support to consumers of mental health service who wish to participate in the annual conference sponsored by the National Mental Health Association. The purpose of the scholarships is to foster transformation of mental health care to focus on recovery. Please note: the completed application and letter of recommendation must be received by March 18, 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

Hotel expense Travel costs: airfare train mileage for car

Have you attended this conference in the past?
Yes No If yes, what year(s)?

Have you ever received a scholarship to attend the NMHA conference in the past?
Yes No If yes, what year(s)? __________________________________

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 22, 2005 to discuss travel arrangements. As a scholarship recipient, you will be asked to do the following:

• Submit a 2 to 5 page report to HSR within 2 weeks of the conclusion of the conference in a format provided by HSR.
• Submit an evaluation form to HSR within 2 weeks of the conclusion conference in a format provided by HSR.
• Submit a travel reimbursement form to HSR within 2 weeks of the conclusion of the conference.
• 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 March 18, 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

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The 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.