Fillable MHSA.2014-2015 Application California State University, Fresno

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MHSA.2014-2015 Application California State University, Fresno

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12/2/2013 Page 1 of 4
California State University, Fresno
DEPARTMENT OF SOCIAL WORK EDUCATION
5310 N. Campus Dr.
Fresno, CA 93740-8019
CalSWEC Public Mental Health Services Act
Stipend Program Application
2014-2015 Academic Year
FILING DEADLINE: FRIDAY, MARCH 14, 2014 AT 5:00 P.M.
The formal list of Program Requirements will be available upon renewal of the program grant.
Part I
Personal Information:
First Name:
Middle:
Last Name:
Mailing Address:
City:
State:
Zip:
Permanent Address:
City:
State:
Zip:
Home Phone:
Work Phone:
County of Residence:
E-mail Address (Fresno State):
E-mail Address (Non-Fresno State):
Date of Birth:
Gender:
M
F (please check one)
Social Security #:
Student ID #:
Ethnicity:
Ethnic Background:
Specify:
Emergency Contact:
Name:
Relationship:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
E-mail:
Person who will know how to contact you after graduation:
Name:
Relationship:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
E-mail:
Person who will know how to contact you after graduation:
Name:
Relationship:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
E-mail:
12/2/2013 Page 2 of 4
Citizenship:
Are you a U.S. Citizen:
Yes
No
If not, please provide a copy of your legal documentation.
Type of document:
Document number:
Expiration Date:
Does your legal documentation permit you to work past graduation?
Does the document have a time limit?
Language Skills:
Are you fluent in another language other than English?
Yes
No If yes, please indicate language(s) below.
Please indicate language:
Please indicate language:
Read:
Read:
Write:
Write:
Driver’s License and Insurance Information:
Driver’s License Number:
State:
Expiration Date:
Auto License Number:
Auto Insurance Company:
Auto Insurance Expiration Date:
Do you have Valid Malpractice Insurance:
Background:
Have you ever been convicted of a misdemeanor or a felony?
Yes
No
If yes, please attach a separate sheet with date(s), location(s), penalties and whether the record is expunged. Each
case will be evaluated and are not necessarily disqualifying (all information is kept confidential).
Part II
Employment and Volunteer Experience (please attach a resume of your work history):
Are you currently employed in a public mental health agency (i.e. county or contract agency)?
If yes, please specify your current employment below:
Job Title:
Agency:
Department:
Job Title:
Unit:
Dates of employment: From:
To:
Total Year(s):
Month(s):
Do you have previous employment in other mental health or related areas?
If yes, please specify your previous employment below:
Job Title:
Agency:
Department:
Dates of Employment: From:
To:
Total Year(s):
Month(s):
Job Title:
Agency:
Department:
Dates of Employment: From:
To:
Total Year(s):
Month(s):
(List any additional mental health or related social services employment on a separate sheet of paper)
12/2/2013 Page 3 of 4
Have you volunteered in other mental health or related area?
If yes, please specify your volunteer work below:
Job Title:
Agency:
Department:
Dates of Employment: From:
To:
Total Year(s):
Month(s):
(List any additional volunteer work on a separate sheet of paper)
Do you have previous employment in other human service areas?
If yes, please specify your volunteer work below:
Job Title:
Agency:
Department:
Dates of Employment: From:
To:
Total Year(s):
Month(s):
(List any additional volunteer work on a separate sheet of paper)
Have you volunteered in other human service areas?
If yes, please specify your volunteer work below:
Job Title:
Agency:
Department:
Dates of Employment: From:
To:
Total Year(s):
Month(s):
(List any additional volunteer work on a separate sheet of paper)
Are you currently on educational leave from human services as a social worker (i.e., mental health, social
services)? If yes, please specify below:
Date of anticipated leave: From:
To:
Part III
Education:
Undergraduate Degree:
Major:
Institution:
Date of Degree:
Expected Date of graduation from the MSW program at CSU, Fresno:
GPA at end of Fall 2013 semester:
Part IV
Statement Addressing Public Mental Health Practice:
This required statement will be used to document your interest in and commitment to a career in public mental
health services. Your application/intent document, statement and an interview with the program
coordinators will be the basis of eventual selection of stipend award recipients.
Your statement must be typed and should not exceed 3 pages (12 point font, 1 inch margins and double-spaced).
Please be sure to address each of the following items.
1. Describe your interest in working in Public Mental Health as a MSW level clinical social worker.
2. Describe your thoughts about how MHSA has advanced mental health practice in California.
3. Discuss how you will benefit professionally from participating in the CalSWEC Public Mental Health
Services Act (MHSA) Stipend Program.
4. Discuss both your short and long term career goals. Be specific.
12/2/2013 Page 4 of 4
Affirmation:
I hereby attest that I have never been discharged from employment with a county or other social services agency
due to violation of county code/merit system rules or violation of agency or professional codes of ethics. Failure to
complete or conform to any of the above stated requirements could result in 1) your withdrawal from the
CalSWEC Public Mental Health Services Act Stipend Program, 2) suspension of your stipend award, and 3) trigger
your immediate obligation to repay monies you have received to date.
I hereby affirm that all information provided in this document for the CalSWEC Public Mental Health Services Act
Stipend Program is true.
Student’s name (please print): ________________________________________________________________________
Student’s signature: ________________________________________________Date: ____________________________
Thank you for your interest in the CalSWEC Public Mental Health Services Act Stipend Program. You will be
contacted to schedule an oral interview. This interview will take about 30 minutes, with the Stipend Program
Project Committee. If you have any questions regarding your application please contact Dr. Betty Garcia at (559)
278-2550, Jenny King-Bates at
jkingbates@csufresno.edu or call Claudia Ceja at (559) 278-6485.
Please sign and submit this application to:
Department of Social Work Education
5310 N. Campus Drive PH 102
Fresno, California 93740
(559) 278-6485
Attn: Claudia Ceja, MHSA Administrative Assistant
Check off list:
Application
Personal Statement
Copy of Immigrant Documentation (if not a citizen)
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MHSA.2014-2015 Application California State University, Fresno

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Completed 31 May 2020

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