CSU, Chico, School of Social Work -- Behavioral Health Services for Transitional Age Youth (BHS-TAY): MSW Workforce
Training Program
Behavioral Health Services for Transitional Age Youth (BHS-TAY)
MSW Workforce Training Program
School of Social Work
California State University, Chico
2016-2017 APPLICATION
APPLICATION DEADLINE: Friday, May 6, 2016 (4:00 p.m.)
Interviews occur the week of May 16, 2016
Applicants will be notified of his/her status by Friday May 27, 2016.
1. Applicant Identification (Please type or print using black ink)
Name: ____________________________________________________________________________________
Last
First
MI
CSU, Chico Student ID#:
DOB:
Ethnicity: __________
Address while at school:
______
Number
Street
City
State
Zip
City
State
Zip
Permanent Address (if different):
_________
Number
Street
Home Phone (
)
Cell Number (
Work Phone (
)
E-Mail Address:
)
Person to contact in case of emergency: ___________________________ Phone: (
________
)
2. Current Field Placement
Please indicate the field agency you have been assigned to for your concentration year or the agencies you have
interviewed with: _________________________________________________________________________
________________________________________________________________________________________
Does the agency assigned to or the ones you have interviewed with provide services to address the needs of
Transitional Age Youth (TAY) at risk for developing or have developed a recognized a behavioral health
disorder in a behavioral health or primary care [ ] Yes
[ ] No
Which agency/agencies
__________________________________________________________________________
CSU, Chico, School of Social Work -- Behavioral Health Services for Transitional Age Youth (BHS-TAY): MSW Workforce
Training Program
4. Language Skills
In addition to English, are you fluent in another language?
[ ] Yes
[ ] No
If yes, please indicate language:
5. Driver's License and Insurance
California Driver's License Number:
Expiration date:
Automobile Insurance Company:
Policy Number:
Type of Coverage:
Expiration date:
Insurance Agent name & phone number:
6. Citizenship
Are you a U.S. citizen?
[ ] Yes
[ ] No
(a) If U.S. citizen - Place of Birth (City, State, County):__________________________________________
(b) If not U.S. citizen, are you eligible to work in the U.S.?
[ ] Yes
[ ] No
Indicate your visa class:
Country of citizenship:
Date of U.S. entry:
7. Essay Questions:
In 500 words or less for each question, please answer the following five questions. Reply to each question
individually. Please type, double-spaced, 12-point font, with your name at the top of each page. Be very
specific and clear in your answers.
1)
2)
3)
4)
Describe your knowledge of integrated health.
What are the BH and health care needs of TAY?
What is the Affordable Healthcare Act and how does it impact TAY?
What professional skills, experiences, and values have prepared you for working with TAY who are at
risk for developing or have developed a recognized behavioral health disorder?
5) What are the personal strengths and attributes that you bring to this training opportunity?
8. Attachments included:
Agency Field Instructor Reference Letter Form (from your current agency if you are currently in the
MSW program or where you completed your most recent practicum if you are entering the One-Year
MSW program).
______ Current Resume
CSU, Chico, School of Social Work -- Behavioral Health Services for Transitional Age Youth (BHS-TAY): MSW
Workforce Training Program
AFFIRMATION AND RELEASE OF INFORMATION
Please initial each statement indicating that you have read and agree to the following:
_____I agree to complete my field placement in a regional behavioral health or primary care
agency that is developing or currently providing integrated health care for TAY who are
at risk or have developed a behavioral health disorder.
_____I agree to participate in all required activities for BHS-TAY training program students
including additional trainings, specialized group supervision (2-hour/week) and related
activities/assignments, group projects, “communities of practice,” evaluation, and any
other related activities.
_____I agree to have use of an automobile, a valid driver's license, and automobile insurance
for bodily injury at all times during this program.
_____I agree to be fingerprinted and to meet the criminal clearance requirements if required by
the agency.
_____ I attest that I have never been discharged from employment at a county or other social
services agency due to violation of county code/merit system rules or violation of agency
or professional code of ethics.
_____I attest that I have never been convicted of a felony or a misdemeanor that would
disqualify me from employment in a county public behavioral agency, community-based
organization, or a primary care setting. Note: The criminal background clearance will
disclose felonies and misdemeanors. If you have questions about this aspect of the
eligibility criteria, please contact Dr. Jean Schuldberg, Project PI/Director (530) 8984187 jschuldberg@csuchico.edu.
_____I understand that post-graduation, I must make a good faith effort to seek, apply, accept,
and provide evidence of employment in an agency that is developing or currently
providing integrated health care for TAY who are at risk or have developed a behavioral
health disorder.
_____I understand that I must sign a Student Commitment contract before participating in the
program and receiving any stipend funds (funds are distributed to participating students
each semester after census date -4th Friday of the semester).
Signature:
Print Name:
Date:
Mail or Deliver Application to:
School of Social Work
California State University, Chico
Butte Hall 511
Attn.: Jean Schuldberg, Ed.D
Chico, CA 95929-0550
Questions: jschuldberg@csuchico.edu
530-898-4187