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HOPE Regional Trainer Application Form
* Indicates required fields

* Name
* Street Address
* City
* State
* Zip Code
  Telephone * Primary Secondary Fax  
* Email Address  
1.   * Gender     Male        Female
2.  * Race/Ethnicity (Check all that apply)
Asian Hispanic/Latino(a)
American Indian/Alaska Native Native Hawaiian or Other Pacific Islander
Black/African American White/Caucasian
Other  (specify)  
3.  * What is your highest level of educational attainment? (Please choose only ONE)
Ph.D. Psy.D. Ed.D. Other  (*specify)  
4.  * Do you provide services directly to HIV-positive individual(s)?
Yes No

5.  * Do you provide services indirectly to HIV-positive individual(s)?
Yes No

If Yes, in what capacity? (Check all that apply)
Administrator/Supervisor Health Educator Student Volunteer
Faculty/Teacher Researcher Other  (*specify)   

6.  * Do you provide services to family members/significant others of HIV-positive individual(s)?
Yes No
7.  * What facility BEST describes the primary setting where you work? (Please choose only ONE)
Academic Institution Hospital/Hospital-based clinic Community Based Organization
Substance Abuse Treatment Long-term Care Not Working
Correctional Facility Religious Organization Private Practice
Hospice Non-Hospital Mental Health Public Health Agency/Clinic
Other  (*specify)   

8.  * Which setting BEST represents where the above work setting is located?
Urban Rural Other  (*specify)  

9.  * Please indicate the number of years that you have provided service in the following areas:
None 2 yrs.
or less		 3-5 yrs. 6-10 yrs. More than 10 yrs
Direct HIV-related clinical mental health services (i.e., therapy)
Indirect services to HIV-positive individuals (see question #5 for example)
10.  * Please choose from the list below to indicate HIV-affected populations with which you have specialized expertise
(you may choose more than one):
Adolescents Asian
Children American Indian/Alaska Native
Men Who Have Sex with Men Black/African American
Injection Drug Users Hispanic/Latino(a)
Seriously Mentally Ill Native Hawaiian or Other Pacific Islander
Women White/Caucasian
Other  (specify)  
11. On what HIV related topics do you anticipate/want to train?  
12. What audience do you hope or anticipate reaching in an HIV training?  

Please upload the following documents (they are required to complete your application):

  • A brief letter describing your HIV-related clinical, research, and training experience, and

  • your Curriculum Vita.
Attach your cover letter
(only .pdf, .doc, & .docx allowed and no larger than 3 Megabytes)
Attach your curriculum vita
(only .pdf, .doc, & .docx allowed and no larger than 3 Megabytes)



Deadline For Submission of Application and Materials is April 25, 2012.





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