Addressing Health Disparities Leadership Program
Application Submission Instructions:
Completed application packets must be submitted electronically (preferred) or by mail to
the National Council for Behavioral Health by 5:00 pm ET on Friday, July 19th, 2013.
Please check the following items to confirm submission of a full application packet:
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Part I: Applicant Contact Information is complete
Part II: Leadership Profile questions have been addressed within the word
limits
Part III: Organizational Profile has been completed
Part IV: Authorized Signature has been provided by the applicant
Letter of Support from supervisor is provided
1-Page Resume is provided
Professional Headshot/Picture is provided
Please Note: Submissions will not be reviewed unless all application materials are
completed and submitted together.
To submit electronically (preferred), please use the following email address:
LairaR@TheNationalCouncil.org.
To submit by mail, please mail to
National Council for Behavioral Health
Attention: Laira Roth
1701 K Street NW
Suite 400
Washington, D.C. 20006
Any questions regarding the Addressing Health Disparities Leadership Program should
be directed to Mohini Venkatesh at 202-684-3730 or MohiniV@TheNationalCouncil.org.
Interested applicants can participate in an informational webinar on Monday, July 8,
2013, from 3:00 – 4:00 pm ET. Register here to participate.
Addressing Health Disparities Leadership Program
2013-2014 Participant Application Packet
Part I: Applicant Contact Information
Name:
Title:
Organization:
Mailing Address:
City, State and Zip:
City:
Phone:
Contact Information:
Secondary Phone (cell):
State:
Zip Code:
Email:
Secondary Email:
(Optional) Please identify your
race/ethnicity:
Part II: Leadership Profile
What, if any, specific activities is your organization involved in to address health disparities (i.e.
administrative, organizational, clinical, or community engagement? (max 200 words)
What is your leadership role in these activities? (max 200 words)
Provide a brief description of your role at your agency, including the day to day activities for which you
are responsible. This should add to, and not repeat, the information provided in your resume. (max 300
words)
What do you consider to be your most significant professional or volunteer accomplishment thus far that
relates to the intent of this program? What was the impact of this accomplishment? (max 300 words)
Please describe your motivation for applying to the Addressing Health Disparities Leadership Program
(max 300 words):
This leadership program will provide you with leadership models, management skills, and strategies to
address health disparities. Please provide a brief summary of a health disparities problem occurring
within your agency that you wish to address through your participation in this program, and thoughts on
how this problem could be addressed. (max 300 words)
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Part III: Organizational Profile
Type of Organization:
Which of the following
describes your
organization? (Check all
that apply.)
1. Public, Not-For-Profit Organization
2. Private, Not-For-Profit Organization
3. Other (Specify):
1. Freestanding community behavioral healthcare provider
2. Hospital-based behavioral healthcare provider
3. Stand-alone addiction provider organization
4. Other (Specify):
Which most closely
describes the
Other:
Rural
Frontier
Urban
organization’s
Specify:
Suburban
geographic location?
Please identify the primary populations that your agency serves (select all that apply):
Ethnicity
Hispanic, Latino or Spanish origin
If yes, please specify:
Mexican, Mexican American, or Chicano/a
Puerto Rican
Cuban
Another Hispanic, Latino, or Spanish origin
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Sex
Male
Female
Race
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Please indicate the percent of types
of behavioral health populations
that your center serves:
Adult
MH
______%
Adult
SU
_____%
Child
MH
_____%
Child SU
_____%
Part IV: Participation Checklist & Authorized Signature
By checking the boxes below, I affirm that I have held these dates & times on my calendar prior to
application submission.
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Program Introduction Webinar: Wednesday, August 13th OR Wednesday, August 21st (time
TBD)
In-Person Meetings:
 2.5 Day Kick-Off Meeting: September 23rd – 25th , 2013 in Washington, DC
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1.5 Day Mid-Program Meeting: February 3rd – February 4th, 2014 in Washington, DC
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2.5 Day Wrap-Up Meeting: Sometime during the week of May 5th, 2014 in Washington,
DC (TBA after selection)
Bi-Monthly Webinars: October 16th, 2013, December 11th, 2013, February 26th, 2014, April
9th, 2014 – all webinars will be held from 3:00 – 4:30 pm ET
Monthly 1:1 Coaching Calls: To be scheduled based on participant availability. Please Note:
These coaching calls may be scheduled during evenings and weekends
Monthly Support Buddy Calls: Participant-led conference calls to be scheduled based on
small group availability
Monthly Homework Assignments & Readings: Participants will be assigned readings and
small writing assignments to explore leadership growth and application of strategies to address
health disparities.
By signing, I agree to participate fully in the activities associated with the Addressing Health Disparities
Leadership program. I understand that should I be selected, all program activities, including in-person
meetings and webinars, are mandatory. I also understand that if I have more than one unexcused
absence from program activities, I will be asked to leave the program.
Signed By: (applicant’s signature)*
Title:
Date:
*Note: Application will not be reviewed without a signature. Applicants may submit a scanned and signed version of
this page or paste an image of his/her signature.
Part V: Attachments
Please enclose the following attachments with your application:
A. Letter of Support from Supervisor. Please Note: Letters of Support must be from the
individual who authorizes applicant’s participation in this program and must clearly
articulate acknowledgement and support for applicant’s participation in all program
activities, including in-person meetings, webinars, and coaching calls, homework
assignments, as well as implementation of Stretch Projects.
B. 1 page Resume. Resumes must highlight educational and employment history, voluntary
activities, association/professional society membership, and any awards/publications.
C. Professional Headshot/Picture. Pictures of program participants will be featured on the
National Council’s website.