MHA Training Request Form

Training Request Form

Mental Health America of Central Carolinas

Thank you for your interest in bringing an MHA of CC Educational training to your organization! Please fill out the Training Request Form below to the best of your abilities and a Community Education Team member will get back to you within 3 (three) business days regarding your request.

*Please note that requests must be made at least 2 (two) weeks in advance of the requested training date.

Group/Organization/School Name:

Group Type:

Name of Person Requesting Training:

First NameLast Name

Contact Phone:

Format: (000) 000-0000.

Contact Email:

example@example.com

Desired Training(s):

QPR and Mental Health First Aid are Certificate trainings. You must agree to provide a roster before the training containing First Name, Last Name, and Email Address for EACH participant at least 2 (two) weeks in advance.

Desired Training Date(s):

*Requests must be made at least 2 (two) weeks in advance.

Preferred Time of Day:

Please specify Morning, Lunchtime, Afternoon, or Evening.

Important Information Regarding Course Maximums

Per the National Council, the maximum # of participants for Mental Health First Aid is 25 people.

Per the QPR Institute, the maximum # of participants for QPR Suicide Prevention is:

In-Person- 30 people
Virtually- 25 people

Anticipated # of Attendees:

*MHA requires a minimum of 10 people.

Desired Training Delivery Method:

Address for On-Site Training:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Does the On-Site location have the following? (Select all that apply.)

Gate or Building Code (if applicable):

Special Parking Info:

Upon clicking Submit below, your request will be received by the Community Education Team and someone will reach out to you within 3 (three) business days regarding your request. Thank you for your interest!

Community Education Team Members

Ashlyn Pemberton - Team Lead

APemberton@mhaofcc.org / 980-374-3544

Tatiana Leon - Youth Partnerships

TLeon@mhaofcc.org / 704-519-2312

Yeferline Gomez - Latino Outreach

YGomez@mhaofcc.org / 980-748-4213