TEC's Mental Health CHW Academy Enrollment Form

TEC's Mental Health Community Health Worker Academy

Complete the enrollment form below to join our WAITLIST for Spring 2026 Cohort, if space becomes available. Learn and gain skills in Trauma-Informed Care, Health & Social Service Navigation, Mental Health First Aid ...and more!
Participant Information
What is your citizenship status?*

U.S. CitizenPermanent ResidentNon-Resident AlienOther
What population group best describes yourself? Check all that apply. Please note: Select at least one to qualify to participate in the High Road Training Partnership program.*

Youth (18-24)Low-Income IndividualsUnemployed IndividualsIndigenous & Tribal CommunitiesCommunities of ColorEnglish-Learning IndividualsJustice-Involved IndividualsIndividuals with DisabilitiesVeteransImmigrants / RefugeesHousing InsecureOther
Are you a California Registered Apprentice or in an Apprenticeship Program?*

YesI'm not sure.No
If you are in a California Registered Apprenticeship, what is the name of the Registered Apprentice Program? If you are unsure if you are in a registered apprenticeship, click here to review: https://www.dir.ca.gov/databases/das/aigstart.asp
What is the industry and occupation for your Apprenticeship?
What is your Division of Apprenticeship Standards (DAS) Registered Apprenticeship number?
If you are participating in a registered apprenticeship, select at least one group to qualify to participate in the California Opportunity Youth Apprenticeship (COYA) program.

Youth (16-24)Justice-Involved IndividualsIndividuals with DisabilitiesCurrent or Former Foster YouthCurrent or Former Pell Grant EligibleCurrently or formerly WIOA Youth or Adult eligibleCurrently or formerly enrolled in a Title I schoolResiding in a high poverty census tractYouth parentOther
Participant Name*

First NameMiddle NameLast Name
Preferred E-mail Address*
example@example.com
Mobile Number*
Format: (000) 000-0000.
Address (Must be a California Resident to Participate)*

Street Address

Street Address Line 2

CityState

Zip Code
Gender
Birth Date*

MonthDayYear
What is your preferred language?*
What is your race/ethnicity?
Click to select all that apply.
Referral Organization

What organization referred you to this program? Who will be your mentor throughout the duration of the 12-week training? (All participants are required to have a program mentor.)
Organization Name:*
Organization Website:
Mentor Full Name:*
Mentor Phone Number:
Mentor Email:
What sector(s) do you or your organization represent?*
Education & Employment Experience
What is your highest level of education completed?*
Are you a Mental Health intern or clinician in need of clinical hours?*
If yes, what is your clinical area of focus?
Are you currently employed?*
Company
Work Number
Format: (000) 000-0000.
What is your current employment position?*
Are you a student and enrolled in high school, college, or training program?*
Where would you like to work in 6-months after the completion of this training? *
How many years of volunteer experience do you have?*
What companies or organizations have you volunteered with?*
Please describe your volunteer duties and experience with serving the community. *
Training Information
TEC's CHW Academy is grant-funded to provide tuition scholarships to participants in need of support. Are you in need of a tuition scholarship?*
All scholarship requests will be reviewed by our Program Team. Please answer the next two questions for scholarship consideration.
What is your annual income level? *
How many individuals are currently living in your household?*
This CHW Academy is 12-weeks in length and includes weekly LIVE and Self-Paced virtual instruction. All applicants must complete the 12 weeks and fully participate in classroom activities, discussions, and assignments. Are you willing to complete the training?*
This CHW Academy is offered virtually and requires full access to technology in order to participate and successfully complete the coursework. Please select the option that best describes your technology access. *
If you selected "No" in the previous question, please describe your need for technology assistance.*

I need internet access.I need a computer with a webcam and microphone.I need a quiet place to complete this virtual training.I need technology assistance (typing, Microsoft Office help, email, etc.) to complete this course.I do not need technology assistance.
If you are a Registered Apprentice, are you in need of any of the following supports or services? Please select all that you need.*

Virtual Weekly Mental Health Small Group SessionsBreakthrough Family Wellness SessionsI need a Gas Gift Card for transportation assistance.I need a laptop.I need internet access.I need emergency housing support.I am not a Registered Apprentice
How did you hear about this training program?*
What is the name of the person that referred you to this program?*
Which training cohort are you interested in participating in? (NOTE: Please select the cohort that you will be committed to complete for our 12-week virtual program.)*

I want to join the WAITLIST for the Spring 2026 Cohort, in January 29th - April 24th, 2026.I am a Registered Apprentice interested in the Spring 2026 Cohort, January 29th -April 24th, 2026 (Must provide verification letter to join.)
Why do you want to complete this training program? *
Do you have a friend, family member, coworker, or colleague that you would like to attend this training program with? If so, we would love for them to join us in our next cohort! Please provide their name and email here.
Additional Comments
Contact Us Today!

www.theempowermentcenterintl.com | (800) 231-7741
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TEC's Mental Health Community Health Worker Academy

Participant Information

Referral Organization

Education & Employment Experience

Training Information

Contact Us Today!