Mental Health Mentorship Training Program Application Form

CALL FOR APPLICATIONS
Mental Health Mentorship Training Program

Mental Health Mentorship Scholar Application

Name:

First Name

Last Name

Credentials:

Address:

City, State, Zip Code:

Email:

Phone:

Alternate Email:

NPI#: (if applicable)

State and License #: (if applicable)

Most Recent Degree:

Year of Graduation:

School:

Other Certification/licensure:

Current Employer:

Current Supervisor:

Supervisor Email:

Please select one.

I AM COVERED BY MALPRACTICE INSURANCE.

I AM NOT COVERED BY MALPRACTICE INSURANCE.

Please provide the following with this application form:

A resume or CV
A 2–4-page summary (not including references) of current work experience and/or career goals in the field of multiple sclerosis, professional goals and objectives for your participation in the MS Mental Health Mentorship Program as well as any plans for education of colleagues upon return from this program.
Letter of recommendation and support from current supervisor/academic supervisor stating commitment and plans for utilization of the skills this course provides.

Return completed application materials via email to Nancy Chazen at nancy.chazen@mscare.org.

Incomplete applications will not be reviewed.

If you are human, leave this field blank.