Wellness and Behavioral Health Specialist Certificate Program Application This application is currently closed. Sign up to Be Notified on Upcoming Sessions "*" indicates required fields PERSONAL INFORMATIONName* First Middle Initial Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* How did you hear about the Wellness and Behavioral Health Specialist Certificate Program?Do you need any accommodations to complete the basic requirements of the program?* Yes No If you answered yes, please explain.Are you currently participating in any educational or training programs?* Yes No If you answered yes, please explain.Are you currently working? Yes, full time Yes, part time No This program is conducted 3 days a week -- Monday, Wednesday, and Thursday -- from 7pm-9pm, from Sept. 22 – Oct. 27, 2025. Are there any days/hours you will not be able to attend? If yes, please note in the box below.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?* Yes No If no, what plans do you have to ensure that you will be able to connect to and complete the program successfully?Do you have or can you install a camera on your computer?* Yes No In what computer programs are you proficient? Select all that apply: Zoom MS Teams Word Email/Outlook Google Chrome Safari EDUCATION & TRAININGPlease upload your resume:* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 3. List all education/training, beginning with the most recent (include name and address of institution, degree/certificates earned, field of study, and dates of attendance).List all prior jobs, beginning with the most recent (include company/agency name and address, job title, dates of employment, and if it was a volunteer or paid position).ReferencesFirst professional or academic reference (full name, phone number/email address, relationship to you):*Second professional or academic reference (full name, phone number/email address, relationship to you):*ESSAYSYou 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.Why do you want to work in the behavioral health/mental health field?*What is your definition of wellness?*What are your career/employment plans following completion of this program?*Consent* I acknowledge that the facts I have stated on this application are true and complete to the best of my knowledge. Should any of this information be found to be false, I understand that it can jeopardize my acceptance/participation in this program. By checking this box I am granting MHALA permission to contact me regarding my application form.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-IdentificationIt 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: 18-24 25-33 34-44 45-53 54-60 60+ Ethnicity (select all that apply): African American/Black Asian American or Pacific Islander Latino/Hispanic Caucasian/White Other Education. Please indicate the highest level of education you have reached. MA/MS BA/BS AA Currently attending college High school graduate GED No high school degree/GED Languages you speak other than English (select all that apply): Spanish Vietnamese Cantonese Mandarin Other Chinese Armenian Russian Tagalog Korean Khmer Hmong Arabic Farsi Other Which of the following best describes you (check all that apply): I am the first person in my family to graduate high school I am the first person in my family to enroll in/attend college I am the first person in my family to graduate from college Several members of my family have attended college Several members of my family have graduated from college NameThis field is for validation purposes and should be left unchanged. Mental Health America of Los Angeles