SAMHSA MFP Prospective Advocate Application

We sincerely appreciate your interest in serving as an Advocate within the LEAD Advocate/Protégé Program. To proceed, kindly complete the application form provided below.

Your commitment to this program is invaluable. Through your involvement, we can continue to offer this exceptional mentorship opportunity to our SAMHSA MFP Fellows. We encourage you to invite your fellow APA/APAF leaders to participate in this enriching initiative.

If you require any further information or assistance, please do not hesitate to contact Razan Jaber at rjaber@psych.org.

1. Contact Information

First Name

Last Name

Title

Institution

City

State

Email Address

Phone Number

2. Your Psychiatric Speciality

3. Your Roles

Administration
Consultation
Direct Patient Care
Research
Teaching
Other - Write In Please enter an 'other' value for this selection.

4. Your APA Leadership Roles

Please enter an 'other' value for this selection.

5. Other Leadership Roles

6. If you've reviewed the PDF with fellow information and identified a potential protégé match, please provide the fellow's name. We'll do our best to accommodate your matching preferences.

7. Please Upload Your Curriculum Vitae

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SAMHSA MFP Prospective Advocate Application - 2024/2025