Write On! application - spring 2019

Young Adult Writers Living with a Mental Health Condition: Be a Part of Write On!

Learn how to find your voice, write your truth, and inspire others to seek help!

Write On! is a writing and advocacy program for people diagnosed with a mental health condition and/or substance use disorder who want to become powerful storytellers and self-advocates. If you are selected to participate, you will advance your skills as a writer, learn how to use writing as a therapeutic tool in recovery, develop the confidence to share your work at public events or through online media channels, and become a vital part of educating your community on the realities of living with a mental health condition.

All interested participants must complete the following application to be considered for entry into the Write On! program. Class size is limited to 15 participants.

If you meet the following criteria, you will be considered as a candidate for selection:

1) I am a young adult (age 18-29) with a mental health condition and/or substance use disorder and am actively in recovery

2) I have goals of being a writer or storyteller, have advanced writing skills that I want to improve upon, and can commit to attending and participating in a 10-week writing workshop

3) I wish to educate the public about the realities and challenges of living with a mental health condition and/or substance use disorder, and will participate in a public awareness campaign through storytelling events and online campaigns

4) I can submit a writing sample of up to 500 words as a part of this application

Complete all questions in this survey.

Completing an application does not secure your spot in the course.

Question Title

* 1. Please indicate yes or no for the following statements:

	Yes	No
I have a mental health diagnosis and/or have experienced trauma that resulted in mental health or substance use challenges.	I have a mental health diagnosis and/or have experienced trauma that resulted in mental health or substance use challenges. Yes	I have a mental health diagnosis and/or have experienced trauma that resulted in mental health or substance use challenges. No
I consider myself as being in recovery	I consider myself as being in recovery Yes	I consider myself as being in recovery No

If you said yes, what does being in recovery mean to you?

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* 2. Name the top TWO reasons you are interested in taking this class:

I need help telling my story and want to improve my writing

I want to advocate for change and educate the community

I want to learn how to use writing as a part of my recovery

I want to become more confident and comfortable sharing my work with the general public

Other (please specify)

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* 3. Rate your current skill level as a writer:

Is there anything in particular with your writing that you’d like to work on? Examples: grammar, voice/tone, building a narrative, etc.

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* 4. Have you had any of your writing published previously? List anything, no matter how limited the audience (blogs, op-eds, school newspapers, etc.).

Yes

If yes, please specify

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* 5. How would you rate your comfort with technology?

Excellent

Good

Fair

Poor

Excellent

Good

Fair

Poor

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* 6. Please copy and paste in a writing sample that is less than 500 words. This can be published work or something you’re working on right now.

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* 7. Do you understand and agree to the following statements? (Click each response to confirm your understanding and agreement to the statement.)

I understand that I am required to obtain my own transportation to/from the weekly class.

I understand that Mental Health Connecticut will provide paper notebooks and pens for supplies. A laptop or electronic writing device is not required for class, but if I want to bring one, I understand that I must supply this equipment.

I understand that if I miss more than two of the weekly in-person classes, I will lose my seat in the class.

I understand that this class will end in a reading and/or online publishing of my work. In other words, my story will be shared with the general public.

I understand that, outside of class, it is my responsibility to obtain access to the Internet to access weekly online group sessions and email.

I am between the ages of 18 - 28.

If you do not agree to any of the above statements, please specify which statement is of concern and why.

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* 8. Please complete the following fields:

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 9. Please complete the following:

Special needs or requests (Type "N/A" or "none" if it does not apply to you)

Environmental concerns or other sensitivities (Type "N/A" or "none" if it does not apply to you)

Emergency Contact name

Emergency Contact phone number

Emergency Contact relation to self

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* 10. I would prefer to attend the class located in . . .

Manchester, CT (at ConnectiCare's Wellness Center, near Buckland Hills Mall)

West Hartford, CT (at Flagg Road Church)

No preference