Community Health Representatives Training Request Form

Community Health Representative Training Request Form

IHS Division of Behavioral Health (DBH), Community Health Representative (CHR) program, and Telebehavioral Health Center of Excellence (TBHCE) in partnership with the University of New Mexico Division of Community Behavioral Health, is pleased to announce Mental Health First Aid training for Community Health Representatives, and other community providers and members.

How does it work? You complete this application. If your program is selected, IHS will cover all of the trainer's costs (time, travel, hotel, meals, etc.). Your program will provide the space for the training and recruit attendees.

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* 1. Contact Information

First Name

Last Name

E-Mail Address

Phone Number

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* 2. Host Organization/Program

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* 3. Training(s) Requesting (Choose One)

ASD:
In this training you will learn things that may indicate a person has Autism Spectrum Disorder. We will review common misunderstandings about Autism. We will talk about ways you and the families you work with can better understand Autism Spectrum Disorder. You will learn plans and skills to help those with Autism Spectrum Disorder do better at home and school.

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* 4. Are you interested in the additional Training of Autism Spectrum Disorder (ASD) (4 hours)?

FASD:
In this training, you were learn things that may indicate a person has Fetal Alcohol Syndrome. We will review common misunderstandings about Fetal Alcohol Syndrome. We will talk about ways you can help support families and advocate for services in schools, clinics, and other community services.

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* 5. Are you interested in the additional Training of Fetal Alcohol Spectrum Disorder (FASD) (4 hours)?

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* 6. Proposed Training Location (Please include city and state)

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* 7. Proposed Training Dates (At least 3)

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* 8. Potential Number of Attendees (Minimum of 20)

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* 9. Do you have leadership support to host this training?

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* 10. If "Yes", please describe.

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* 11. Do you have partnerships or co-hosts for this training?

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* 12. If "Yes", please describe.

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* 13. Additional Comments/Information

Thank you for your request. If you have any questions and/or comments please contact Angela Banks-Harris at abanksharris@salud.unm.edu or (505) 272-1566.

Thank you