1. 1

2. 2

3. 3

4. 4

5. 5

6. 6

7. 7

8. 8

9. 9

10. 10

11. 11

12. 12

13. 13 http://datawarehouse.hrsa.gov/GeoAdvisor/ShortageDesig nationAdvisor.aspx Type in your facility address and click “submit” Next to “Mental Health Professional Shortage Area” the query will state “yes” or “no” Mental Health Professional Shortage Area Your employer receives funding from the federal, state, county or city government A publicly funded facility or a publicly funded or public mental health facility Not-for-profit hospital, clinic or long-term care facility Licensed/certified by California DMH and/or DHCS A non-profit private mental health facility

14. 14

15. 15

16. 16

17. 17

18. 18

19. 19

20. 20

21. 21

22. 22

23. 23

24. 24

25. 25

26. Two professional references Dated within six months of deadline (dated between 9/24/10- 3/24/11) Formatting requirements: Letterhead OR Contact Information– see instructions Signed and Dated 26

27. 27

28. 28

29. 29

30. 30

31. 31

32. 32

33. 33