Wellness and Behavioral Health Specialist Certificate Program Application
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PERSONAL INFORMATION

Name*
Address*
Do you need any accommodations to complete the basic requirements of the program?*
Are you currently participating in any educational or training programs?*
Are you currently working?
This program takes place on Zoom and requires access to a computer. Due to the classroom activities, the classes cannot be accessed by using a phone. Do you have access to a working computer and reliable Internet/WiFi connectivity?*
Do you have or can you install a camera on your computer?*
In what computer programs are you proficient? Select all that apply:

EDUCATION & TRAINING

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Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 3.

    References

    ESSAYS

    You application essays are very important to your application. Your essays provide an opportunity for the team to learn more about you. We strongly suggest you prepare and save your essays for this application in a Word document and cut and paste into the application.

    Consent*
    It is the policy of Mental Health America of Los Angeles to provide equal internship opportunities to all qualified applicants without regard to race, color, religion, ancestry, national origin, sex, age, marital status, sexual orientation, veteran’s status or presence of disability.

    Voluntary Disclosure of Self-Identification

    It is the policy of Mental Health America of Los Angeles to provide equal internship opportunities to all qualified applicants without regard to race, color, religion, ancestry, national origin, sex, age, marital status, sexual orientation, veteran’s status or presence of disability. While it is your choice to provide us with the following information, it is important that we are successful in our efforts to reach out to a diverse constituency. We appreciate you providing us with the following demographic information to help gauge the success of these efforts.

    Age:
    Ethnicity (select all that apply):
    Education. Please indicate the highest level of education you have reached.
    Languages you speak other than English (select all that apply):
    Which of the following best describes you (check all that apply):
    This field is for validation purposes and should be left unchanged.

    Mental Health America of Los Angeles