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Mental Health First Aid Instructor Certification Program Application




Thank you for your interest in Mental Health First Aid. The National Council for Community Behavioral
Healthcare is delighted to review your application for the Instructor Certification Program. The
Instructor Certification Program is a 5-day training after which attendees are certified to offer the 12-
hour Mental Health First Aid training. If selected, your organization will be responsible for participant
tuition, travel, hotel, and any miscellaneous expenses. Tuition is $1850 per person. We recommend
that each organization send at least two participants. Attendees of the Instructor Certification Program
are required to remain at the training for all five days. Although the number of 12-hour Mental Health
First Aid trainings offered each year will vary based on the organization and target audiences, the
National Council expects certified instructors to offer at least three trainings per year to maintain
certification.


             National Instructor Certification Program: Washington, DC, June 28-July 2, 2010


In this application packet, you will find:
1) Cover Sheet


2) Agency/Organization Questionnaire
This questionnaire should be completed by the primary contact for Mental Health First Aid at your
organization. This could be your organization’s CEO or other senior manager who will be most involved
in the development and management of Mental Health First Aid trainings in your community.


                  Please return your completed application to Susan Partain at
            susanp@thenationalcouncil.org or via fax 202.386.9391 by May 3, 2010
ph 202.684.7457 | fax 202.684.7472 |
                                                                                 www.TheNationalCouncil.org
                                            Cover Sheet


      Organization Name


            Address


 Is your organization a National
                                                          YES                    NO
        Council member?
  MHFA Primary Contact Name


         Position/Title

         E-mail Address

           Telephone


   Address (if different than
            above)

Does your organization have an
   active public education                                YES                    NO
          program?
                                    Private Non Profit       Public Non Profit        Other (describe)
  What is your organizational
                                         Agency               County Agency
          structure?
 Which most closely describes           Rural             Frontier       Urban        Suburban     Other
      your service area?
 Please list the counties your
     organization serves:

  If selected as a MHFA site,
when do you plan to launch the
 program (i.e. offer the first
           training)?
                                   Name:
    Participant Information
                                   Title:
                                   Name:
    Participant Information
                                   Title:


Application Deadline: 5 PM eastern time, May 3, 2010


                                                                                                         2
ph 202.684.7457 | fax 202.684.7472 |
                                                                                  www.TheNationalCouncil.org
Agency/Organization Questionnaire


1) How does Mental Health First Aid (MHFA) complement the services and/or trainings you are
currently offering in your community?




2) Who do you envision as the primary target audience for roll-out of Mental Health First Aid in your
community? Please identify initial and long-term potential audiences, including a tentative timeline for
your roll-out.




3) What is your plan for promoting and funding Mental Health First Aid? Also briefly describe your long-
term sustainability plan.




                                                                                                           3

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Instructor certification program questionnaire dc newfax

  • 1. Mental Health First Aid Instructor Certification Program Application Thank you for your interest in Mental Health First Aid. The National Council for Community Behavioral Healthcare is delighted to review your application for the Instructor Certification Program. The Instructor Certification Program is a 5-day training after which attendees are certified to offer the 12- hour Mental Health First Aid training. If selected, your organization will be responsible for participant tuition, travel, hotel, and any miscellaneous expenses. Tuition is $1850 per person. We recommend that each organization send at least two participants. Attendees of the Instructor Certification Program are required to remain at the training for all five days. Although the number of 12-hour Mental Health First Aid trainings offered each year will vary based on the organization and target audiences, the National Council expects certified instructors to offer at least three trainings per year to maintain certification. National Instructor Certification Program: Washington, DC, June 28-July 2, 2010 In this application packet, you will find: 1) Cover Sheet 2) Agency/Organization Questionnaire This questionnaire should be completed by the primary contact for Mental Health First Aid at your organization. This could be your organization’s CEO or other senior manager who will be most involved in the development and management of Mental Health First Aid trainings in your community. Please return your completed application to Susan Partain at susanp@thenationalcouncil.org or via fax 202.386.9391 by May 3, 2010
  • 2. ph 202.684.7457 | fax 202.684.7472 | www.TheNationalCouncil.org Cover Sheet Organization Name Address Is your organization a National YES NO Council member? MHFA Primary Contact Name Position/Title E-mail Address Telephone Address (if different than above) Does your organization have an active public education YES NO program? Private Non Profit Public Non Profit Other (describe) What is your organizational Agency County Agency structure? Which most closely describes Rural Frontier Urban Suburban Other your service area? Please list the counties your organization serves: If selected as a MHFA site, when do you plan to launch the program (i.e. offer the first training)? Name: Participant Information Title: Name: Participant Information Title: Application Deadline: 5 PM eastern time, May 3, 2010 2
  • 3. ph 202.684.7457 | fax 202.684.7472 | www.TheNationalCouncil.org Agency/Organization Questionnaire 1) How does Mental Health First Aid (MHFA) complement the services and/or trainings you are currently offering in your community? 2) Who do you envision as the primary target audience for roll-out of Mental Health First Aid in your community? Please identify initial and long-term potential audiences, including a tentative timeline for your roll-out. 3) What is your plan for promoting and funding Mental Health First Aid? Also briefly describe your long- term sustainability plan. 3