I-RISE Application - Center for Practice Transformation

Name*

First Last

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Type of Licensure*

LPCC
LICSW
LMFT

Please indicate with which community you identify: [Select all that apply]

Black/African American
Asian American/Pacific Islander
Native American/Native Alaskan
Hispanic/Latinx
Country of origin is not the United States
LGBTQ+
Physically disabled

By checking this box, I certify that I agree to serve at least 25% of my annual encounters to people that meet the following criteria:*

Enrolled in publicly subsidized insurance such as Medicaid, Medicare -and/or- Receiving sliding fee schedule discounts through a formal schedule meeting the standards established by the United States Department of Health and Human Services under Code of Federal Regulations, title 42, section 51, chapter 303.

I certify that I agree to serve at least 25% of my annual encounters to people that meet the above criteria.

By checking this box, I certify that I am not the recipient of, nor will I apply for, an individual grant from the MHCCCE Program through MDH if I am deemed eligible for the I-RISE program.*

Individuals who have received or who are applying for the Mental Health Cultural Community Continuing Education (MHCCCE) individual grant funded through Minnesota's Department of Health (MDH) are not eligible for this funding opportunity.

I certify I have not received MHCCCE funds, nor will I apply for the MHCCCE grant upon receiving I-RISE grant funding.

All information included in this application is complete and true to the best of your knowledge.*

By checking this box, you are certifying that all information included in this application is complete and true to the best of your knowledge. Any submission of falsified or misleading information will result in removal from the program and a requirement to pay back grant funds received to date.