Protégé Application - MPATTC Learning

Step 1 of 5

20%

HHS Region

What region are you applying for?(Required)

HHS Region 5 Great Lakes ATTC (Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin)

HHS Region 6 South Southwest ATTC (Arkansas, Louisiana, Oklahoma, Texas, New Mexico)

HHS Region 8 Mountain Plains ATTC (Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming)

HHS Region 9 Pacific Southwest ATTC (participation open to individuals living and working in Arizona, California, and Nevada)

Protégé Information

Name(Required)

First Last

Credentials(Required)

Current Role/Position(Required)

Agency/Organization(Required)

Mailing Address(Required)

Street Address City State ZIP Code

Workplace Setting(s)(Required)

Substance use disorder treatment program

Recovery support program

Mental health clinic or treatment program

Criminal justice/corrections

Higher education

Hospital/health center

Tribal/Indian Health Service

State/county/jurisdiction/territorial/tribal government

Other community-based organization

Specify(Required)

Daytime Phone Number(Required)

Email Address(Required)

Upload a CV or Resume(Required)

Accepted file types: pdf, Max. file size: 5 MB.

Do you currently supervise other staff?(Required)

Yes

How many individuals do you supervise?(Required)

How many years have you supervised other staff members?(Required)

Name of person that referred you to the Leadership Academy(Required)

Short Answer

Please provide detailed responses (approx. 4-6 sentences) to the following questions:

Provide 3 examples that best describe your leadership skills and potential.(Required)

What type of skills training would be of benefit to your future role as a leader?(Required)

Why should you be selected for this opportunity?(Required)

Certification and Agreement

The purpose of the Leadership Academy is to enhance the knowledge of a diverse group of promising individuals at an optimal point in their career. The program is designed to help participants prepare for greater responsibility and increase contributions to their agency, and the substance use prevention, treatment, and recovery support fields.

I understand that continued agency support is imperative for a Protégé’s successful completion of this eight-month process. If I am selected as a Leadership Academy protégé, my organization/agency agrees to support me by:

allowing the time required for full program participation as a protégé;
allowing the protégé time for continuing education; and
providing the protégé support and understanding during the process.

Consent

I understand and agree to the time commitment for all the activities to fully participate in the 2027 Leadership Academy.

Those selected to participate in the Leadership Academy will need supervisor approval by signature. If selected, additional information will follow.

2027 Leadership Academy Pre-Survey

This survey should take no more than 10 minutes and is designed to capture your current leadership skills and organizational context. If you are accepted as a Protégé in the 2027 Leadership Academy, you will be asked to complete a follow-up survey in the Fall at the end of the Academy.

Creating a confidential ID to link your pre- and post-academy surveys

To help us link your responses over time while maintaining your privacy, please follow the instructions for creating your unique identifier

1. Please enter the first letter of your first name

2. Please enter the last two letters of your last name

3. Please enter your birth month as a number (MM)

Background

4. What is your primary occupation/profession? (Select one):

Addictions Professional

Psychiatrist

Psychologist

Counselor/Therapist

Social Worker

Recovery Coach

Peer Recovery Specialist

Prevention Specialist

Case Manager/Care Coordinator

Clinical Supervisor

Faith Leader

Administrator

Researcher

Pharmacist

Nurse/Nurse Practitioner/Physician/Physician Assistant

Teacher/Educator

Student

Other

Specify

5. In what State or Tribal Community do your work?

6. What is the highest degree you have received? (select one)

Less than 12th grade

12th grade/High school diploma/Equivalent

Vocational/Technical (Voc/Tech) Diploma

Some College or University

Bachelor’s Degree (For example: BA, BS)

Graduate Work/Graduate Degree

Leadership Skills Self-Assessment and Organizational Context

7. Please indicate how frequently you engage in the following behaviors at work.

	Have not had the opportunity to do	Almost Never	Sometimes	About half the time	Usually	Almost Always
Listen carefully to input and feedback from others
Communicate effectively with all levels of staff
Collaborate internally and externally to build relationships and achieve common goals
Encourage people to work collaboratively to achieve goals
Make data-informed and timely decisions
Set work priorities while considering resource requirements
Readily adapt to new information, changing conditions, or unexpected obstacles
Generate buy-in with staff around proposed system or practice changes

8. Please select your level of agreement.

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
I know how to manage and resolve conflicts in a constructive manner and create a safe environment for the expression of diverse opinions.

9. Please indicate the extent to which you agree with each statement.

	Not at all	Slight extent	Moderate extent	Great extent	Very great extent
My supervisor recognizes and appreciates employee efforts toward successful implementation of evidence-based practice
My supervisor supports employee efforts to learn more about evidence-based practice
My supervisor supports employee efforts to use evidence-based practices