BMH Residency™ Application
First Name
Last Name
What is your ethnicity?
American Indian or Alaska Native
Black or African American
Asian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Bi-Racial
White
Other
Social Media Handles
Date of Birth
Email
Phone/Mobile
Address
Address Line 1
City
State
Zip Code
Education Level
Did not complete high school
GED
HS Diploma
Currently enrolled in college/program
Certificate
Associate Degree
Bachelors Degree
Masters Degree
PhD
What is your household size?
Employment Status
Please share your annual income
Do you need a scholarship?
Yes
No
Do you have reliable access to Wi-Fi?
Yes
No
Not at this time, but I'm working on it
Do you know how to utilize Microsoft Word/Google Docs
Yes
No
Not at this time, but I'm willing to learn
Do you know how to upload images, pdf and word documents as an attachment
Yes
No
Not at this time, but I'm willing to learn
Do you have reliable & consistent access to a laptop or PC?
Yes
No
Not at this time, but I'm working on it
Do you have reliable & consistent access to transportation?
Yes
No
Not at this time, but I'm working on it
Do you have any disabilities or learning support needs?
Please share with us why you're interested in the BMH Residency™ program.
Please share with us why you're interested in advancing your BMH career.
What do you plan to do after becoming a Certified BMH Professional?
Start a private practice business
Join a BMH agency or organization
Work as a BMH professional in a hospital
Work as a BMH professional in a clinic
I'm unsure
Are you applying for hybrid or Online only?
Hybrid
Online only
Cover Letter & Resume
Choose File
Letter of Intent
Choose File
Statement of BMH Activities & Work
Choose File
Prior Certification
Choose File
Legal ID
Choose File
Submit BMH Residency™ Application
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