LivingWorks Education (LWE) is thrilled to host a

LivingWorks Education (LWE) is thrilled to host a safeTALK Training for Trainers (T4T) May 11 & 12, 2015 at La Verne
Church of the Brethren, 2425 E Street, La Verne, CA 91750. The deadline for submission is April 16, 2015.
Name of Applicant
Telephone Number
Email Address
Address
City
County
Supervisor Name
Telephone Number
Organization/Affiliation
Zip
Email Address
I have read the Essential Information for safeTALK T4T Candidates?
Y/N
I have attended an ASIST 2-day workshop?
Y/N
If no, how will you complete this safeTALK T4T prerequisite?
My supervisor is aware of the duties of a safeTALK Trainer and supportive of your T4T application?
Y/N
I am able to attend the entire T4T training? (see attached schedule)
Y/N
I plan to stay at the local hotel? If so, which nights? ____________________ Out of town participants are
encouraged to stay locally. CalMHSA funding covers up to $200 of the hotel stay.
Y/N
Where and for whom will you provide your safeTALK workshops?
My agency’s plan for incorporating safeTALK Training into their normal business operations include:
I will make time to prepare for your first workshop by doing the following:_
I/my agency will cover the costs associated with safeTALK workshops (participant materials, site, refreshments, preparation
time) by:
Please email your completed Letter of Interest to:
Kathleen Snyder, Kathleen.snyder@livingworks.net
phone: 916.316.2076
** These trainings are funded by the voter-approved Mental Health Services Act
(Prop. 63). It is one of several Prevention and Early Intervention Initiatives
implemented by the California Mental Health Services Authority (CalMHSA), an
organization of county governments working together to improve mental health
outcomes for individuals, families and communities. CalMHSA operates services and
education programs on a statewide, regional and local basis.