IHELP Fellowship Application

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Fellowship Application

APPLICATION DEADLINE August 3, 2022

Fellowship Start Date *

I am applying for the Fellowship for Summer or Fall 2022

Only select one and it must coincide with when you begin internship. Occupational Therapy students follow the guidelines given by Dr. Seruya

Demographics

Name*

First Name

Last Name

CWID*

Mercy College Email Only*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone (best Number)*

Training

Program of Study*

Mental Health Counseling Marriage and Family Therapy Occupational Therapy School Counseling

Culminative Graduate GPA *

Transcript* No File Chosen

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Academic Recommendation (e.g. faculty) (if applicable) No File Chosen

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Field Placement Full Name *

First Name

Last Name

Field Placement Full Address*

HPSA Number (https://data.hrsa.gov/tools/shortage-area/by-address)

https://data.hrsa.gov/tools/shortage-area/by-address

Essay

Provide a 500-word essay as to why you wish to provide behavioral health services to children, adolescents, and transitional-aged youth (e.g. college age) who are at risk for behavioral health disorders in high need high demand areas after graduation.

Submit Essay Here* No File Chosen

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Signature

If selected, I agree to comply with the IHELP standards:

•To complete 5-7 hours per month of additional education including activities such as webinars and interprofessional events.

•To work be open with working with children, adolescents, and transitional-aged youth and families in the Bronx or a medically underserved area

•To provide demographic information during the internship experience

•To discuss fellowship with Site Supervisor to receive training as well with compensation.

•To be open with working in behavioral health with children, adolescents, and transitional youth in economically disadvantaged and underserved communities after graduation.

•To provide post-graduation information

Signature*

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Fellowship Application

Demographics

Background

Training

Essay

Signature