Licensed Mental Health Services Provider Education Program: How to complete your application

Mental Health Loan Assumption Program (MHLAP)Funded by the Mental Health Services Act (MHSA) in partnership with the California Department of Mental Health.Application Instructions

1Access the Application2http://www.oshpd.ca.gov/HPEF/MHLAP.html

Click here to access the ApplicationGo to the Application Website

23PDF Fillable ApplicationYou may save the application to your Desktop or a folder on your computer and fill in electronically or print the printable version.

If you choose to print and handwrite the application please be sure your writing is legible.

Either way you will still need to print and mail the application in.

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Program Overview

4You may be awarded up to $10,000

The 2010/2011 average award was $9555.

The award is in exchange for a commitment to work or volunteer for 12 months in a hard-to-fill or retain position in the County Public Mental Health System.

Eligible professions including registered Interns may apply. The eligibility of your position is determined by your County Mental Health Director /Designee and based on a Countys needs for that year. The Foundation handles the verification of your application.

There is no preference given to one profession over another in the award process or the award amount given.

Not all applicants will receive an award. For the 2010/2011 Cycle 47% or 474 of the total applicants were awarded.

4Program Background 5MHLAP is administered by the Health Professions Education Foundation in partnership with the Department of Mental Health.

It is funded by the Mental Health Services Act (MHSA).

MHLAP Awards help repay educational debt.

5Check Your Eligibility!You must have a valid legal presence to work in California.

You must not have an existing service obligationA prior obligation is OK if your contract expires prior to 7/1/2012

If you are Board Certified you must have a valid license, registration (Intern) or waiver.

Your loan must be with an educational lender.

You must be working or have a letter of hire to work or volunteer in the Public Mental Health System.

Your completed application must be postmarked no later than 12/10/11.

After submission your position will be verified by the Foundation as being hard-to-fill or retain by your County of employment. 6

6Application Instructions7

Print your name at the top of pages 2-7

Personal Statement and Lender informationIf you provide a separate page for your personal statement be sure and print your name at the top of the pageDo not use a font smaller than 11 on your Personal StatementYour Lender Statement(s) must have The Lenders NameServicing Company Name if differentPayment AddressApplicants NameDated within 6 monthsCurrent BalanceAccount Number

Proof of LicensureCopy of License, Intern/ Registration or Waiver should accompany the application

7Application: Page 1

Enter all requested personal information

County of Employment is the County where you work.

Phone numbers and email are very important. Email is how we communicate with you. Please provide us with an email address that you check frequently. If it changes you must immediately provide the Foundation with a new one.

Please indicate your Ethnicity. The Foundation uses this for statistical purposes only

Current Service ObligationDo you currently receive a stipend or are you a recipient of an Award from another program? Will your service obligation for the stipend or award overlap with MHLAP (6/30/12-6/30/13)?Have you received an award from the MHLAP? Please indicate dates.

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Application: Page 2

Your name needs to be at the top of pages 2 through 7.

Briefly describe how your experiences have contributed to your cultural or linguistic competence.

Please give a brief example only if the statement applies to your experience.

Do not submit your examples on a separate page. You must use the space provided on the page. Additional pages will not be accepted.

Points assigned for the depth and quality of your response not the number that you give.

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910Application Page 3

If the name of your employer or organization is different than the program where you work or volunteer be sure to indicate both.

You must include your direct Supervisors name and contact information.

Give both your profession/discipline and job title.

Indicate any languages that you use fluently at work with mental health clients.

Indicate how your time is spent at work.

YOU MUST WRITE IN THE TOTAL HOURS PER WEEK YOU WORK.

List your primary job functions.

Your Direct Supervisor or an Authorized Entity (HR) or whoever may verify your employment and hours per week, must sign and date.

1011Application: Page 4

Loans in forbearance or deferment maybe eligible. If your loan is in default or you are in bankruptcy you are not eligible.

Give the name of Bank or institution that owns the loan this is your lender.

If you send your payment to a company other than your lender they are considered the Loan Servicer and you must include their name.

The payment address is not the Lenders correspondence address. You must find and send the correct address for an award to be made.

Enter your loan information in the order you want the loans to be paid. The maximum award is $10,000.

Depending on your loan balance/s you may need to fill in sections 1 to 3 with lender information. You will need to send lender statements for these loans and the information needs to match the information on Page 4.

If you have more educational loans than indicated in sections 1-3 please indicate this in section 4. You do not need to send lender statements for these other loans.

Indicate the total educational debt for the other loans reflected in section 4.

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Professional GoalsElaborate on the type of organization you hope to work for and the population or community you hope to work within the next 5 years

Where you hope to work Indicate your top 2 choices of where you hope to work in the next 5 years

List your unpaid community involvement in the past 5years:Include community service or volunteer activities emphasizing if there is a connection with mental health:In the community at large With the community or population you work with. This could include church, school, club or other organization.Professional memberships.Not just a paid membership Explain if you are active and involved.

12The Personal Statement is your opportunity to elaborate on how your life experiences have contributed to your work in the Public Mental Health System.

Please do not use a Font size less than 11.

Do not send more than one page. Use either the space on page 6 or use 1 additional page. YOU MAY NOT USE BOTH.

If you choose to handwrite your statement please be legible.

13Application: Page 6

1314Application: Page 7

You must fill in the Contact section at the top of Page 7 to insure we can reach you with Award information.

Application CertificationRead and Understand

Letter of UnderstandingRead and UnderstandThis is a Formal and Binding Contract Notify the Foundation of ANY Changes during the application process or your service obligation

SIGN and DATE If not signed you will be disqualified

14Lender Statements

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15Proof of Licensure, Registration or WaiverLicensed PsychiatristsPsychologistsMarriage and Family Therapists Clinical Social WorkersLicensed Clinical Professional Counselors Mental Health Nurse Practitioners:Provide a copy of your license

Registered PsychiatristsPsychologistsMental Health Nurse PractitionersMarriage and Family Therapy InternsAssociate Clinical Social Workers:Provide a copy of your registration

Postdoctoral Assistants Trainees Individuals who are not required to register through their Board (waivers determined by DMH):Provide a copy of the your waiver letter

Any other profession licensed with a California BoardProvide a copy of your license if applicable

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If you are one of the professions listed on this page you must send in proof (a copy) of your license, registration or waiver:16Awardee ResponsibilitiesFrom June 30, 2012 to June 29,2013 continue working in the position you held when you first applied for the Award. If you change employers or positions you will need to be re-verified by your County Mental Health Director. If your new position is not approved as eligible you will lose your Award (awards are not pro-rated).

Provide no less than 20 hours per week service If you work fewer than 20 hours due to furlough or reduced work schedule please indicate clearly.

Remain in the same County of Employment that you were verified in. If you choose to no longer work for the County you were approved in, you will lose your award.

Continue making your required loan payments. Awardees are paid at the end of their 12-month service obligation (June 2012-June 13). The Foundation is not responsible for any late payments or penalties you may incur during this time.

Do not enter into any other Loan Repayment Program or Stipend Contract throughout the application process or service obligation. You may not overlap your service obligations to receive more than one award or grant. 17

17Common Pitfalls You have a current or prior award service obligation that will overlap your service obligation with MHLAP.You do not write in your Birth Date, Drivers license number or Social Security number on your application.Your Supervisor/Authorized Entity does not Sign and Date Page 3.Your loan is not with an educational lender.Page 4 is not accurate or doesnt match the lender statement/s.You do not send in correct Lender information and documents.The narrative sections on Pages 2, 5, and 6 are handwritten or the Font used is too small to read and understand.Sending in extra pages for narrative questions. They will not be scored. You do not provide Contacts on Page 7 you must include them.You do not Sign and Date Page 7 if not signed you will be disqualified.A copy of your license, registration or waiver isnt sent in.18

18When and where do I submit the materials?19

It is best to submit All documents 3 to 6 weeks early

Must be postmarked on or before:Saturday, December 10, 2011

Mail to:Health Professions Education FoundationATTN: MHLAP APPLICATION 400 R Street, Room 460 Sacramento, CA 95811

19Contact InformationMail your application and all documents to:

Health Professions Education FoundationATTN: MHLAP400 R Street, Room 460Sacramento, CA 95811

For Questions:Frequently Asked Questions at: www.healthprofessions.ca.gov/mhlapCounty contact List at: wwwhealthprofessions.ca.gov/mhlap Phone: (800) 773-1669 (916) 326-3640Foundation Website at: www.healthprofessions.ca.gov

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