Licensed Mental Health Service Providers Education Foundation (LMH)

1. Licensed Mental Health Service Providers Education Foundation(LMH) 2012 Application Instructions

2. Access the Application http://www.oshpd.ca.gov/HPEF/LMHSPEP.html

3. PDF Fillable Application • It is recommended you fill in the application electronically. • You must have Adobe Acrobat Reader on your computer to view the application. If you do not have Acrobat Reader, please click on the link to download it. • You may save the application to your Desktop or a folder on your computer . • If you choose to handwrite your application it must be legible. If the reviewer cannot read or understand your answers you may receive less points. • Either way you will need to print and mail the application in.

4. Program Overview • You may be awarded up to $15,000 per application cycle. • You may be awarded twice with this award. • Funding comes from licensure fees from the Board of Behavioral Sciences and the Board of Psychology. • The award is in exchange for working or volunteering for 24 months. • You are qualified in a the position you apply under. If you change jobs you will need to be re-qualified. • The award helps repay educational loans only. Credit card or home loan debt will not qualify for this repayment award. • Not all applicants will receive an award. 34 of the 142 applicants who applied for the 2011 Cycle received an award.

5. Check Your Eligibility! • You must have a valid legal presence to work in California. • You must not have an existing service obligation • A prior obligation is OK if your service obligation ends prior to 7/1/2013 • You must send in a up-to-date copy of a valid license or registration certificate. • Your loan must be with an educational lender. • You must be providing direct patient care working or volunteering in a qualified facility or clinic with an eligible organization or agency. • Your completed application must be postmarked no later than 9/11/12. • Two (2) letters of recommendation must accompany your application.

6. Application Instructions • Read the definitions on the last page of application. • Print your name at the top of each page. • The two (2) letters of recommendation must be dated within 6 months of application deadline. Letters should be on letterhead and include author’s original signature, title, name of their organization, address, phone number and email are required. Faxes, emails and electronic signatures will not be accepted. • A copy of your License or Intern/ Registration certificate must accompany the application. • If you use a separate page for your personal statement be sure to print your name at the top of the page • Do not use a font smaller than 10 on your Personal Statement • Your Lender Statement(s) must have • The Lender’s Name • Servicing Company Name (if different than lender) • Payment Address • Applicant’s Name and account number • Must be dated within 6 months of deadline • Current loan balance

7. Application: 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 will communicate with you. Please provide us with an email address that you check frequently. If your email changes you must immediately provide the Foundation with a new one. • Current Service Obligation • If you currently receive a stipend or are a recipient of another Award please indicate the dates of your service obligation here. • If you have received an award from LMH or MHLAP please indicate the dates of your service obligation.

8. Application: Page 2 • Your name needs to be at the top of the page. • Your answers must fit into the space given for each question. Do not use a font smaller than 10. If you handwrite your answers, the reviewer must be able to read and understand them for you to receive points. Be sure it is legible. • 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. Smaller than a 10 font

9. Application: Page 3 • List your unpaidcommunity involvement in the past 2 years • Educational or licensure internships do not count • Service does not need to be in the mental health field however emphasize 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, clubs or other organizations

10. Application: Page 3 • The Personal Statement is your opportunity to elaborate on how your life experiences have contributed to your work in the mental health field. • Please do not use a Font size less than 10. • Use either the space on the page or use 1 additional page. YOU MAY NOT USE BOTH. • If you choose to handwrite your statement please be legible or you may lose points. • Ask a friend to read it to see if it is understandable and readable. Smaller than 10 font

11. Application Page 4 • You must include your direct Supervisor’s name and contact information. • Give BOTH your profession/discipline and job title. Your profession (example: MFT or LCSW) is important for our statistics and funding. Your job title may not indicate this and it is important. • Indicate any languages that you are required to use at work. • Indicate how your time is spent at work. • YOU MUST indicate your duties and the time that is spent on them every week. This must be filled in and total hours must be reflected. • Your Direct Supervisor or another Authorized entity (HR)/ must verify your employment and hours by signing.

12. Application: Page 5 • Loans in forbearance or deferment are eligible. If your loan is in default or you are in bankruptcy you are not eligible. • Your lender is the Bank or institution that owns the loan • If you send your payment to a company other than your lender they are the Loan Servicer and you must include their name. • If the payment address is not the Lender’s correspondence address. You must find and send the correct payment address. • Enter your loan information in the order you want the loans to be paid. The maximum award is $15,000. • Depending on your loan balance/s you may need to fill in sections 1 to 4 with lender information. You will need to send lender statements for each and the statement needs to match this.

13. Application: Page 6 • You must give us 3 contacts to insure we can reach you with Award information, payment questions, or quarterly monitoring forms. • ApplicationCertification • Read and Understand • Letter of Understanding • This is a Formal and Binding Contract be sure to read it • Note: you must notify the Foundation of ANY changes during your service obligation • SIGN and DATE • If not signed you will be immediatelydisqualified

14. Lender Statements

15. Proof of Licensure, Registration or Waiver YOU MUST SEND IN PROOF (a copy) OF YOUR license or registration : • Licensed Psychologists Marriage and Family Therapists Clinical Social Workers Licensed Clinical Professional Counselors: Provide a copy of your license • Registered Psychologists Mental Health Nurse Practitioners Marriage and Family Therapy Interns Associate Clinical Social Workers: Provide a copy of your registration • Postdoctoral Assistants/Interns/Trainees Individuals who are not required to register through their Board (waivers determined by DMH): Provide a copy of the your registration or waiver letter

16. Awardee Responsibilities • Continue working in the position you were qualified when you first applied for the Award. If you change employers or positions before you are awarded you will need to be re-verified. If your new position is not eligible you can not be awarded. If you change jobs during your service obligation and are no longer eligible you will lose your award and have to pay back the any award money you received with interest. • Provide no less than 32 hours per week service • Continue making your required loan payments. Awardees are paid quarterly during their 24-month service obligation. 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. Common Pitfalls • You have a current or prior award service obligation that will overlap your service obligation with LMHSPEP. • You do not write in your Birth Date, Driver’s license number or Social Security number on your application. • Your Supervisor or Authorized Entity does not Sign and Date. • Your loan is not with an educational lender. • Lender Page is not accurate or doesn’t match the lender statement/s. • You do not send in correct Lender information and documents. • The answers in the narrative sections are not readable or understandable. • You send in extra pages for narrative questions. They will not be scored. • You do not provide Contacts – you must include 3 of them. • You do not Sign and Date Application – if not signed you will be disqualified. • A copy of your license, registration or waiver isn’t sent in.

18. Contact Information Mail your application and documents by or before September 11, 2012 to: Health Professions Education Foundation ATTN: LMH/HPEF/OSHPD 400 R Street, Room 460 Sacramento, CA 95811 Frequently Asked Questions at: www.healthprofessions.ca.gov Phone: (800) 773-1669 (916) 326-3640 Foundation Website at: www.healthprofessions.ca.gov