Candidate Information & Application Form
The 2015 Leadership Institute
A Unique Leadership Development Program for
Mid- to Upper-Level Behavioral Health Professionals
Candidate Information & Application
Application Process
The Mid-America ATTC 2015 Leadership Institute is open to persons who work in behavioral health treatment agencies in Arkansas, Kansas, Missouri, and Nebraska. Candidates must be nominated by leadership within their agency. If you have received this application, leadership from your agency has nominated you! If you are interested in participating, submit an application form and current resume. Agency nomination forms and candidate applications must be e-mailed () or faxed (816-235-6512) to Deborah Rockford by March 13, 2015. Nominators and candidates will then participate in phone interviews. The 2015 Leadership Institute Selection Committee will review applications and select participants based on the criteria described later in this document. Phone interviews, strength of the candidate’s application and timely receipt of nomination/application will also be considered. Early submissions are encouraged. Selected candidates will be notified in late March.
Program Cost
Mid-America ATTC will provide:
· Three online assessments: 360o Leadership Skills Assessment; Myers-Briggs Personality Inventory (MBTI); and Thomas-Kilmann Conflict Mode Instrument
· Five-day Immersion Training with national trainer
· Mentoring in areas of development identified during the Immersion Training
· Online business course titled Strategic Business Decision Making. Participants will gain skills in completing an environmental scan in their agency. This process will identify opportunities and threats as well as organizational strengths and weaknesses, how to use scenario planning to consider alternate futures which may result from each, and how to apply strategies to address these. The course involves online instruction, videos, readings, group conference calls and coaching in strategic business decision making.
· One-day Commencement Ceremony includes short presentation by each participant to an audience comprised of Mid-America ATTC staff, Protégés and Mentors, in addition to a representative from each sponsoring agency
· Lodging and meals during Immersion Training and Commencement, as well as all curriculum and training resources
The sponsoring agency will be responsible for:
· $500 registration fee due upon notification of acceptance
· Travel to and from Kansas City for a five-day Immersion Training and one-day Commencement
· Reimbursement of meals incurred during travel to and from Immersion Training and Commencement. Lodging expenses and meals will be provided by Mid-America ATTC during the two events.
· Providing an e-mail address dedicated solely to the participant and accessible during work hours
· Supporting development of individual leadership skills as identified from assessment results during the Immersion Training
· Allowing time for the participant to participate fully in program
Application Criteria
Candidates for the program must be employed in a behavioral health treatment agency and be nominated by their CEO or director. It is critical that the agency agree to and allow for the time necessary to complete all requirements, and provide the protégé with opportunities to test new skills.
Nomination and application forms are screened, and protégés selected for the program by the Mid-America ATTC Leadership Institute Selection Committee.
The Selection Committee will select 12 protégés for the program who:
· Exhibit professional commitment to the behavioral health treatment field. Preference will be given to applicants who have worked in the field five years or more.
· Are currently employed in a supervisory or management position within a behavioral health agency. Preference will be given to applicants with at least five years’ experience as a manager or supervisor.
· Demonstrate current and potential leadership as indicated by professional, volunteer and other activities or through recommendations
· Have bachelor’s degree or higher. Preference will be given to applicants with a master’s degree.
· Make a commitment to participate fully in all training activities, including an assessment of personal leadership skills by superiors, peers and subordinates and completion of an online business course
· Have received employer’s commitment to fully support participation and allow for the time required to learn and apply the leadership model. Commitment of the employer is demonstrated by submission of a nomination form.
Time commitment needed to complete the program involves:
Date(s) / Program Elements / LocationMarch – April 2015 / Online assessments, which includes inviting supervisor, peers, and subordinates to give feedback for a 3600 leadership skills assessment / Employment Site
May 18 – 22, 2015 / Five-day Immersion Training / Kansas City, MO
May - September 2015 / · Regular contact with mentor, monthly conference calls, and time to apply acquired knowledge
· Online business course
· Schedule 2-5 hours during the work week for course work, mentoring / Employment Site
September 2015 TBD / Commencement & Presentation / Kansas City, MO
Please direct application questions to:
Mid-America Addiction Technology Transfer Center
Deborah Rockford – (816) 235-5057 or
Application Form
Application Form
(to be completed & submitted by candidate)
Your agency has submitted your name as a candidate for the Mid-America ATTC 2015 Leadership Institute. Please read through the accompanying information and consider your willingness to participate in this extended professional leadership development opportunity. If you do NOT want to participate in the Leadership Institute, please inform your agency now.
If you are interested in pursuing this unique opportunity, please complete the application and essay. Your comments are confidential and are not shared with your agency leadership. The Selection Committee members appreciate the time and care necessary to prepare this application. Please fill out the application form electronically.
Name: ______Credentials: ______
Title: ______Department: ______
Agency: ______
Agency address: ______
City: ______State: ______Zip: ______
Work phone number: ______Work fax number: ______
Work e-mail address: ______
# of employees in agency: ______# of people you supervise: _____ # of peers in agency: _____
Home address: ______
City: ______State: ______Zip: ______
Home phone number: ______Cell phone number: ______
Personal e-mail address: ______
The following two data fields are OPTIONAL. This information is included to help create a balanced protégé group, if possible.
1. Gender 2. Race/Ethnicity
Male Caucasian
Female Black or African-American
r Male Hispanic/Latino
r Female Asian
r Male American Indian
r Female Native Hawaiian/Pacific Islander
r Female Alaska Native
1) Please submit a TYPED essay which includes responses to the following questions – not to exceed 3 pages.
§ Describe your reasons for interest in this program.
§ Describe the scope of your current leadership roles.
§ Describe are your leadership strengths and development needs.
§ Describe the next professional position to which you aspire.
§ Describe your dedication to the treatment/recovery field.
§ Describe the characteristics you seek in a mentor.
2) Submit a current resume with your application.
3) Rate your effectiveness when using a computer in the workplace.
Not Effective / Sometimes Effective / Often Effective / Effective / Highly Effective4) I use e-mail at work:
Don’t use / Occasionally / Weekly / Daily / Many Times a Day5) I have access to the internet:
At Work / At Home6) I have experience using the following computer programs (list programs you are comfortable using – i.e. Microsoft Word, etc.):
7) I have worked in the behavioral health/recovery field for _____ years. (You may also describe other work experience you would like the Selection Committee to know about.)
8) I have supervised and/or been a manager in this field for _____ years. (You may also describe leadership roles you have filled in other settings.)
9) Leadership Competency Dimensions
Please rate your effectiveness in the following areas of leadership. Check your responses by double clicking the shaded box and choosing the “checked” option.
Managing people and tasks: Demonstrates such skills as coordinating, teamwork, leadership/influence, managing conflict, and planning/organizing.
Not Effective / Sometimes Effective / Often Effective / Effective / Highly EffectiveProblem solving and decision making: Demonstrates skills through problem identification, insight, seeing things from new angles, recognizing trade-offs, decisiveness, and action.
Not Effective / Sometimes Effective / Often Effective / Effective / Highly EffectiveCommunicating: Demonstrates effective oral and written communication skills and active listening.
Not Effective / Sometimes Effective / Often Effective / Effective / Highly EffectiveBuilding and maintaining relationships: Demonstrates skills that build interpersonal relationships, negotiating,
putting people at ease, and showing compassion and sensitivity.
Not Effective / Sometimes Effective / Often Effective / Effective / Highly EffectiveMobilizing innovation and change: Demonstrates the ability to conceptualize, inspire, act creatively to mobilize innovation and change, risk-taking and visioning.
Not Effective / Sometimes Effective / Often Effective / Effective / Highly EffectiveManaging self: Demonstrates self-directed learning, personal organization/time management, personal strengths, and problem solving/analytical skills.
Not Effective / Sometimes Effective / Often Effective / Effective / Highly EffectivePersonal professional demeanor: Demonstrates integrity, projecting a professional image, and ethical practice.
Not Effective / Sometimes Effective / Often Effective / Effective / Highly EffectiveCertification and Agreement
The purpose of the 2015 Leadership Institute is to enhance the knowledge and skill of a diverse group of promising leaders at an optimal point in their career. The program is designed to help Leadership Institute participants prepare for greater responsibility and contributions to their agency in a changing healthcare environment, and ultimately, the behavioral health treatment and recovery field.
My Commitment
I understand that continued agency support is imperative for my successful completion of this six-month process. I understand that if selected to participate in the Leadership Institute, my agency will be responsible for a portion of the expenses incurred in this extended training program.
I understand that my agency agrees to support my successful completion of the Leadership Institute by (check all that apply):
Allowing me the time required for full program participation including time to participate in conference calls, attend two required events, complete an online business course and project, and receive mentoring for development of growth areas identified during the Immersion Training.
Providing travel and meal expense during travel to and from the two required events.
Providing an e-mail address dedicated to me which is accessible during work hours.
Paying $500 registration fee following my selection into the program.
In addition, I affirm the following:
The information provided in this application is correct.
If chosen for the 2015 Leadership Institute, I will participate fully.
Candidate Signature: ______Date: ______
Application should include:
Application Form
Essay
Current Resume
Submit applications to:
Deborah Rockford
Mid-America ATTC – UMKC
Email:
Telephone: 816-235-5057
Fax: 816-235-6512
2464 Charlotte, HSB
Kansas City, MO 64108
Application – Page 4 of 4