Fw; CMHS Consumer Affairs E-News: SAMHSA/CMHS Consumer Scholarships Available

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Consumer Affairs News from the Center for Mental Health Services

http://www.mentalhealth.samhsa.gov/consumersurvivor/

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CMHS Consumer Affairs E-News December 16, 2003 Vol. 03-116

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SAMHSA/CMHS Consumer Scholarships Available for NMHA 2004 Conference

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 conference sponsored by the National Mental Health Association

(NMHA). Please note, the completed application (below) and letter or

recommendation must be received by March 5, 2004 in order to be eligible

for this scholarship.

The National Mental Health Association (NMHA) 2004 Annual Conference

Hyatt Regency Washington on Capitol Hill, Washington, DC

June 9-12, 2004

Conference information available at: 1- or www.nmha.org

Application for Financial Support

Application deadline: March 5, 2004

Consumer Scholarship Application

Contact Information:

NAME:

ORGANIZATION:

ADDRESS:

CITY:

STATE:

ZIP:

PHONE:

FAX:

E-MAIL:

Demographic Information:

Optional Information. The following optional information is intended to

help ensure diversity of scholarship recipients. Provision of this

information is voluntary and does not affect chances of acceptance.

Gender:

Male ____

Female ___

Age:

18 – 25 ___

26 – 55 ___

56 + ____

Ethnicity:

Asian/Pacific Islander ___

American Indian ___

Black (not of Hispanic origin) ___

Hispanic ___

White (not of Hispanic origin) ___

Other ___

Sexual Orientation:

Lesbian ____

Bisexual ____

Heterosexual ____

Gay ____

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 ____

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 May 7,

2004 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 to HSR within 2 weeks of the conclusion of the

conference.

3. Submit a travel reimbursement form to HSR within 2 weeks of the

conclusion of the conference.

4. Inform the HSR if you are unable to attend the conference or will be

delayed in meeting the other two 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 5, 2004 by:

Hauser

Health Systems Research, Inc.

1200 18th Street, NW, Suite 700

Washington, DC 20036

Phone:

Fax:

E-mail: shauser@...

Pager:

(Please leave your phone number including area code and we will return

your call as soon as possible.)