SBH Fellowship Application

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Synagogue affiliation (name of synagogue)*

Role(s) in which you impact your community: (Please check all that apply)*

Rabbanit/ Rebbetzin
Kallah Teacher
Educator
Kesher Teacher
Other

Please elaborate on your "other" role.*

This role is:*

Volunteer
Paid

Please describe your communal role in more detail and the context in which you work with community members.*

Please describe the population you engage with in your communal role.*

Education and employment*

Please list your educational degrees and institutions and previous places of employment.

Age range

Mental heath training*

I have previously participated in mental health training programs and/or conferences

yes
no

Please share the name of the program, the host organization of the program and a short description of the program.*

Please describe the challenges you face serving in your communal role*

Goals*

Please describe what you will gain from this fellowship and how it will impact your personal life and your communal work.

Program agreement*

I understand that if awarded the fellowship, I will attend the three in-person programs at SBH on Tuesday, December 1 (10 AM - 2 PM), Tuesday, December 15 (7:30 - 10 PM), and Sunday, January 10 (10 AM - 2 PM). I will participate in all three virtual sessions "live with video on." Sessions take place on Zoom from 8-10 PM on Tuesday evenings - December 15, 22 and January 5. I will also attend my one-on-one meeting with SBH staff.

Additional comments

The purpose of this course is to provide general information to assist you in your communal work with respect to when and how to refer to appropriate mental health professionals. This course is not intended, and should not be construed, as formal training, permission to practice as a mental health counselor or for certification or license in the mental health field.

I am not a mental health counselor and do not counsel in a professional capacity.

Reference

Please share the name and contact of a reference who can speak about your communal role and impact should the OU decide to reach out.

Reference

The reference has agreed to speak on my behalf and to share the contact information below.

Name of reference*

First Last

Email address of reference*

Phone number of reference*

APPLICATION

Reference