Application: Mental Health First Aid Instructor Certification Training


Part I: Applicant Information

Name:


(first, last)

 

Title:

     

Applicant Type:

         ☐I am applying as an independent trainer


         ☐I am applying as an agent of my employer


         ☐Other, please specify:      

Organization Name:


(if applying as an agent of your employer)

     


 


 

Organization Type:

         ☐Private


         ☐Public


         ☐Not-for-profit


         ☐For-profit


         ☐Other, please specify:      

Industry Type:

         ☐Faith community


         ☐Corporate


         ☐Human resources/Employee Assistance Program


         ☐Law enforcement/public safety


         ☐Higher education


         ☐Primary/secondary education


         ☐Hospitality


         ☐Older adults


         ☐Social services


         ☐Behavioral healthcare


         ☐Other healthcare


         ☐Government


         ☐Other, please specify:      

Organizational Service Area:

         ☐Urban


         ☐Suburban


         ☐Rural


         ☐Frontier

Email:

     

Primary Phone Number:

     

Secondary Phone Number:

     

Mailing Address:

     

Desired Training Date and Location:


(For a full list of trainings offered, click here.)

1st Choice


Date:      


Location:      


 


2nd Choice


Date:      


Location:      

Are you applying for a youth or adult instructor training?

         ☐Youth


         ☐Adult

Full or expedited training?

         ☐5 Day training for new instructor


         ☐2.5 Day training for current instructor

Does your organization have a primary contact for Mental Health First Aid activities?

         ☐No


         ☐Yes


 


If yes, please provide the name and contact information.


Name:      


Email:       


Phone number:       

Does your organization have an active community/public education program?

         ☐Yes


         ☐No

How did you find out about the instructor training program?


 

         ☐Employer email


         ☐Employer requirement


         ☐Professional relationship


         ☐Personal relationship


         ☐Internet search


         ☐MHFA USA Website


         ☐MHFA Instructor


         ☐Have attended 8 hour course


         ☐Other, please specify:     

Part II: Applicant Experience and Qualifications


Please note that each response will be scored. You are encouraged to provide as much detail as word limit permits.

1. Why do you want to become an instructor? (max 200 words)


     

1)    2. Please provide a description of your personal and/or professional experiences in the field of mental health that qualify you to teach a Mental Health First Aid course (i.e. clinical experience, personal or family history, social service experience, etc.). Please provide time frames for any relevant experience.  (max 300 words)


     

2)    3. Please provide a description of your experiences in adult instruction that would qualify you as a strong candidate to be an effective Mental Health First Aid instructor (i.e. group facilitation, teaching, etc.). Please provide time frames for any relevant experience. (max 300 words)


     

3)    4. Have you taken a Mental Health First Aid course?


         ☐Yes


         ☐No


 


If yes, when did you take the course (mm/yy):      

4)    5. What other skills or experiences do you have that you believe will support your success as a Mental Health First Aid instructor? (max 200 words)


     


 

Part III: Understanding of Program

5)    6. What does the term “mental health” mean to you? (max 200 words)


     


 


6)    7. What factors do you believe create and maintain the stigma associated with individuals who have mental health problems? (max 150 words)


     


 

8. What are the key messages of Mental Health First Aid? (max 200 words)


     


 

9. What do you believe are the skills and attitudes needed to be an effective Mental Health First Aid instructor? (max 150 words)


     


 

10. What would you do if during one of the Mental health First Aid training sessions you are conducting, a participant approaches you privately about a personal mental health problem s/he is experiencing? (max 250 words)


     


 

11. How does Mental Health First Aid support/complement the work you or your organization is already doing? (max 200 words)


     


 

Part IV: Strategic Plan for Implementation

12. Please provide some examples of how you have effectively networked with organizations, local services, or other partners within your community to support an initiative (i.e. public education initiative, community event, volunteering, etc.). (max 200 words)


     


 

13. Mental Health First Aid is intended to have a broad appeal to the public. Please describe your plan to implement this program in the next year. Be sure to include information about how to plan to secure funding, how you plan to market your courses, who you will partner with, and what audiences you plan to target. (max 400 words)


     


 


14. When do you plan to teach your first course and who will be your target audience? (max 150 words)


     


 

15. What are some potential barriers you may face when trying to implement your above strategies? (max 200 words)


     


 


 


Instructor Application Reference Document


To be considered for the Mental Health First Aid Instructor training, each instructor applicant is required to submit a reference document.  No application will be reviewed until both the application and reference document have been received.  Please note that references are subject to phone verification.  By submitting this form, you are giving permission to Mental Health First Aid USA to contact your reference.


 


Selection of Reference 


Please select an individual to complete this form who can attest to your suitability of becoming a Mental Health First Aid Instructor.  It is important that this individual knows you and your work well enough to be able to thoughtfully and completely respond to the all questions below. 


 


Directions 


Please share this document with your chosen reference.   When completed, please have your reference return this form to you so that you can submit it with your application.


 


First name:      

Last name:      

Organization Name:      

Address:                                        City/State/Zip:      


Email:                                             Phone:      


 

How long have you known this applicant?      


 

What is your relationship to this applicant? (I.e. in what capacity have you known this applicant?)      


 

Please describe the role and responsibilities that you believe this applicant will be taking if he/she becomes a Mental Health First Aid Instructor?      


 

Why do you think this individual would be successful in training others in Mental Health First Aid?      


 

How would you describe the candidates’ attitude towards people with mental illness and substance use disorders?      


 

Please rate the applicant in each of the areas below:

 

Poor

Below Average

Average

Very Good

Excellent

Knowledge of mental health


 

Ability to effectively facilitate a full day training with an audience of up to 30 people

Ability to engage with audiences that are very diverse in terms of their knowledge base and beliefs about mental health and substance use issues


Instructor Candidate Commitment Form

A signed, scanned copy of this form must be submitted as a part of the application packet.

 

Becoming a successful Mental Health First Aid instructor requires a serious commitment of time, energy and creativity.  Similarly, it requires awareness and support of the program, fidelity to the course, understanding of the certification requirements, and commitment to demonstrating best practices in teaching and facilitation. By signing this Commitment Form, you agree to adhere to the following conditions at all times during the instructor training and subsequent to certification.

 

I hereby agree to:

  1. Fully engage in the Instructor Training by committing adequate time, energy, and enthusiasm throughout the program and conduct myself in a professional manner at all times.

  2. Follow all course requirements for instructors. This includes:

    1. Teaching the course for the full 8 hours

    2. Training to an audience of no less than 10 and no more than 30 unless given permission to do so by MHFA USA

    3. Providing hard-copy, non-duplicated manuals for each course participant

    4. Using current slides and films for all course sections

    5. Providing a resource list to all course participants

    6. Providing MHFA certificates to participants only after a participant has satisfied all course requirements. 

  3. Follow all data requirements in WIMS related to courses including:

    1. Registering all courses prior to course date

    2. Entering all course participants no later than 72 hours after course has taken place

    3. Collecting and providing to Mental Health First Aid USA within 7 days of course completion, all course evaluation and attendance sheets (course data must be entered in order for the instructor to receive credit for the course)

  4. Maintain “good standing” as an instructor requires:

    1. Teaching the course at least 3 times, each year

    2. Completing re-certification two years from the date of certification

    3. Passing Quality Evaluation visits and maintaining satisfactory evaluation scores

    4. Engaging in instructor/course re-fresher activities as required

    5. Keeping Instructor Profile Updated with current email address

    6. Keeping informed and adhering to MHFA program developments and changes by reading all MHFA communications

  5. Appropriate use of MHFA materials:

    1. None of the information, documents, manuals or videos may be reproduced in any form, in whole or in part without the written permission of MHFA USA. Instructors may not sell or otherwise transfer materials to a third party. Only certified instructors may use the materials provided

    2. The course curriculum may not be modified without the expressed written permission of MHFA USA

       

       

       

       

       

       

       

  6. To the best of my ability, incorporate best practices in presenting, facilitating, and teaching groups into my courses.

    1. Operationalizing techniques to engage course participants

    2. Using an appropriate tone, volume, pace, and rhythm when teaching a course

    3. Appropriately managing participant interactions

  7. Continuously convey and appropriately demonstrate the scope and role of a Mental Health   First Aid instructor during my courses. This includes:

    1. Continuously convey and appropriately demonstrate the scope and role of a Mental Health   First Aid instructor during my courses. This includes:

    2. Serving as an ambassador of Mental Health First Aid

    3. Using personal disclosure of experiences in an appropriate manner

    4. Respecting the privacy of course participants, colleagues and other, including the responsibility to protect personal information on paperwork and in gaining permission to share personal stories or experiences of others

       


      Instructor Signature

      Date: __________________________

      Instructor Signature: ______________________

      Instructor Name (printed): ____________________

      Employer Signature (if applying as an agent of your employer)

      Date: __________________________

      Direct Supervisor Signature: ______________________

      Direct Supervisor Name (printed): ____________________

       

       

      Submission directions: Please return your completed application to <contact> at <contact email or other address> by <deadline date & time>.

       

       

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