APPLICATION FOR HRSA/BEHAVIORAL HEALTH WORKFORCE PRACTICUM
The purpose of this grant is to develop and expand the behavioral health workforce that works
with children, adolescents, and transitional-age youth (16 to 25 years old) who are at risk or who
have developed a recognized behavioral health disorder. If selected, your participation will
include an advanced year practicum in an identified setting and required attendance at seminars
to support the experiential learning. A stipend will be provided for the academic year; the exact
amount will be determined by HRSA in spring semester.
Name_____________________________________________________________________
Address___________________________________________________________________
City/State/ZipCode__________________________________________________________
Phone___________________________ Email ___________________________________
Macro or Clinical
Current Advisor____________________________________
Foundation Year Placement___________________________________________________
Please attach a copy of your resume, including your Foundation Year placement.
In a separate document, please address the following questions in two pages or less:
1. What are your interests and/or experiences in working with the identified at-risk
populations in behavioral healthcare?
2. Discuss the skills, knowledge and values that bring you to this project.
3. What are your career goals with respect to behavioral health and the vulnerable
populations targeted in this grant? Professionally, where do you see yourself in five
years?
To be considered for this program, you must be in good standing in the MSW program, i.e. no
incompletes, no unresolved difficulties with Academic Standards Review Committee and have
successfully passed both Field I and II.
By signing below, you give us permission to access your current GPA, contact your Foundation
Year advisor, and to share information about your background with project staff. Please also
sign and return the commitment letter as well as the waiver section for the Reference form.
Signature_________________________________________________________
Date____________________________
Please return the completed application to the Field Education office, McGuinn Hall 204C.
DUE Friday December 11, 2015 at 1:00PM
1
HRSA/BEHAVIORAL HEALTH WORKFORCE PRACTICUM
COMMITMENT LETTER
If selected as a participant of this program the student will agree to the following:
1. Complete an advanced year placement at the agency of the committee’s choosing that
provides training in behavioral healthcare service delivery to children, adolescents, and
transitional-age youth (16 to 25 years old).
2. Comply with the requirements of the Advance Year practicum, which includes a
minimum of 720 hours over the academic year; active participation in supervision; and
completion of the written requirements of the course, such as learning contract, process
recordings and others as outlined in the Field III & IV syllabi.
3. Attend all scheduled interprofessional seminars as scheduled by the committee.
4. Abide by BCSSW policies for academic integrity and ethical behavior as outlined in the
Student and Field Education Guides.
5. Understand that acceptance into this program is conditional on continued good standing
within the BCSSW. Concerns regarding suitability will be addressed directly with the
student by the members of the program committee.
6. Intend to pursue a career in the US working with children, adolescents, and transitionalage youth at risk of developing or who have developed a recognized behavioral health
problem upon completion of the MSW degree.
Please sign if you agree with the items outlined above.
Name (please print) ______________________________________________
Signature______________________________________________________
Date___________________________
2
REFERENCE FROM FOUNDATION YEAR ADVISOR
NameofStudent:___________________________________________________________
Phone: ________________________Email:____________________________________
HRSA
Student Reference from Foundation Year Advisor
Date:_____________________________
NameofAdvisor:___________________________________________________________
Phone: ________________________Email:____________________________________
Date:_____________________________
Under the provisions of the Family Education Rights and Privacy Act of 1974, you will have access to the
information provided unless you have waived such access. Please sign and date below to inform us of
your decision.
I hereby waive my right of access to the
information in this recommendation.
I do not waive my right of access to the information
in this recommendation.
_________________________
Signature of Applicant
_________________________
Signature of Applicant
_____________
Date
______________
Date
From: Susan Coleman, LICSW, Director of Field Education
220 McGuinn Hall
Email: susan.coleman@bc.edu
Phone: 617-552-0774
Fax: 617-552-1095
We appreciate your assistance in helping us determining the student’s suitability for a placement in
integrated behavioral health care delivery with children and youth. Access to this reference is restricted
to appropriate faculty and to the student unless s/he has waived the rights under P.L. 93-568, as indicated
above. In assessing the applicant’s aptitude for this program, please frame her/his qualifications for
professional education in the context of the following questions.
I. Please rate the applicant in comparison with others whom you have known at a similar stage in their
careers.
Exceptional
Upper 5%
Outstanding
Next 15%
Motivation & commitment to
social work
Motivation and perseverance
towards goals
Ability to work independently
Ability to express thoughts in
speech and writing
Ability to work with people of
diverse backgrounds
3
Very Good
Next 15%
Good
Next 15%
Poor
Next 15%
No Basis for
Judgment
II. Kindly provide the following information to the best of your knowledge about the applicant.
A. What do you know about her/his skills and ability to work with younger populations
facing behavioral health challenges?
B.
What do you know about her/his skills and ability to work with diverse populations
and/or in a cross-cultural setting?
Would you recommend this applicant for a placement in an integrated care setting with children,
adolescents and transitional age youth at risk of developing or who have developed a behavioral
health disorder?
If no, please explain your answer.
Yes q
No q
Please attach any additional information that you believe would help in determining the student’s
ability to be an active participant in this program.
Thank you for taking the time to complete this reference form.
Name: ____________________________________________
Signature: _________________________________________
Date: _____________________
4