ASK GATEKEEPER TRAINING OF TRAINERS APPLICATION FOR

ABILENE & WEST TEXAS SCHEDULED FOR JUNE 23, 2011.

Mental Health America of Texas will provide:

·  Free one-day training for new ASK Instructors

·  Certification to Instructors upon successful completion of training, test and essay

·  Free information support materials including PowerPoint, training script, handouts, evaluations

·  Free continuing technical assistance on suicide prevention

Trainee agrees to:

·  Attend complete one-day ASK training in its entirety, quiz and essay

·  Review information materials provided by Mental Health America of Texas prior to the training

·  Conduct 3 local training a year for 3 years

·  Send required evaluations to Mental Health America of Texas following each training

·  Provide own travel costs at no cost to Mental Health America of Texas

·  Cover own costs as it relates to providing local ASK gatekeeper workshops

Submit Application: Because there are a limited number of slots available, we need you to submit this application. Send application to both email addresses below no later than May 23, 2011, and we will confirm space, if available: Merily H. Keller, Master Trainer instructor – and

Mary Ellen Nudd, VP Mental Health America of Texas –

1. Your name, title or volunteer group, agency/place of employment:

2. Email, phone number and cell number: (please share home and work in case you move from current position in future so we do not lose contact with you)

3. Work address:

4. Address to which we should send materials if not above address:

5. Other training in suicide prevention you have received such as school, graduate school or continuing education courses, other gatekeeper training such as QPR, ASIST or others:

6.  Please tell us in a couple of sentences why you are interested in being a trainer of trainers in ASK About Suicide Prevention Gatekeeper Training:

7.  Please tell us what groups or audiences you expect to present ASK Gatekeeper Training Workshops in the future:

8.  If you have lost a close friend or family member to death by suicide, please indicate date of loss. We prefer that a trainer be at least 1 year past the loss before leading workshops.