Mental Health First Aid (MHFA) Interest form

Thank you for your interest in Mental Health First Aid (MHFA) Through this training you will learn how to identify, understand and respond to signs of mental health and substance use challenges among adults. This training covers the following topics:

• Common signs and symptoms of mental health challenges. • Common signs and symptoms of substance use challenges. • How to interact with a person in crisis. • How to connect a person with help. • Expanded content on trauma, substance use and self-care.

In-person learners will receive their training as an 8-hour, Instructor-led, in-person course. Blended learners complete a 2-hour, self-paced online course, and participate in a 4.5- to 5.5-hour, Instructor-led training. Upon completion of all tasks, you will receive a certificate as a proud and newly certified Mental Health First Aider.

*Please note that all trainings are on the Hattiesburg campus unless otherwise indicated via email.*

Have you completed the MHFA certification in the last 3 years?*

Yes No Unsure

USM EMPLID #/student ID w#*

Name*

First Name

Last Name

Race

African American American Indian/Alaska Native Asian White (non-Hispanic) Native Hawaiian/Other Pacific Islander Multi-racial Other Prefer not to answer

This demographic data is being collected as a requirement of federal funding which supports the costs of the MHFA training.

Gender

Female Male Non-binary Other Prefer not to answer

This demographic data is being collected as a requirement of federal funding which supports the costs of the MHFA training.

Email*

Campus*

Role/Position*

College of/Division of

School/Department

Program

How many years have you worked in Higher Education total?*

Preferred Date of Training

**Please note the deadline to the accept invite and be enrolled is two days prior to your chosen date of training.**

After completing this initial registration you will receive an invitation by email (to be accepted two days prior to training date)to register with the national website. Then, you will be required to complete a 2-hour, self-paced online course prior to the in-person training. Participants who have not been enrolled by 5pm of the deadline will no longer have access to the course. If pre-work is not completed by 7am of the morning of the training, then participants will not be eligible to participate in the in-person, instructor-led class. Do you agree to these terms?*

Yes No

MHFA training, typically, requires an in-person commitment of 5.5-6.5 hours. Do you agree to participate for that length of time?*

Yes No