CHCs will complete a Cover Sheet providing information about the eligible interns they wish to have considered for this funding. Following the identification of the intern(s), the CHC will need to provide the name, contact information, and a summary of the selected intern’s strengths and how they will support behavioral health care delivery for diverse and/or rural population of patients at their health center and/or help create a more diverse behavioral health workforce.
CHCs will be asked to include any intentions to hire the identified intern post the completion of their internship. A maximum of three cover sheets can be submitted per CHC. A total of twelve interns will be awarded in the sixth year of this program.
Information that will be asked for in the Cover Sheet:
1. CHC information
Name of Organization
Organization Address
Primary Application Contact
E-Mail Address
Organization CEO/Equivalent
E-Mail Address
Organization CFO/Equivalent
E-Mail Address
Behavioral Health Director
E-Mail Address
2. Student information
Selected Student Intern
E-Mail Address
Student Type (Social Work, Mental Health Counselor, Family and Marriage Therapist, Doctoral Psychology Student)
Internship Start Date
Internship End Date
3. Letter of Support
(limit to 500 words) Please provide a brief summary of the selected student’s strengths and how they will support behavioral health care delivery for the diverse population of patients at your health center and/or help create a more diverse behavioral health workforce. Please include any intention that will be made to hire your identified intern post the completion of their internship.
4. Approval from CHC CEO and BH Director
By typing the name of your CEO/Executive Director and Behavioral Health Director below, you attest that you are all in agreement to releasing the intern, if awarded, from any clinical duties in order to attend the Learning Community Sessions provided through this program.
