MAP Attestation Form

Purpose of the Attestation Form: This form serves to officially confirm your understanding of the requirements and commitment to the MAP training program. Completing this form is required for your agency to receive funding.

Instructions for Completion:

Review: Carefully review the information provided in the attestation form.
Download a copy: Click the button below to download the attestation form for your records.
Complete the online form: Fill out all required fields on the online form. You do NOT need to complete the version your download.
Each trainee participating in MAP training should complete an attestation form.

Contact Information: If you have any questions or require assistance regarding the attestation process, please contact nicole.wang@nyulangone.org.

Managing and Adapting Practice (MAP):

Evidence-Based Practices in OMH-Licensed Community-Based Provider Agencies to Serve Children with Significant Mental Health Needs and their Families

Attestation

The New York State (NYS) Office of Mental Health (OMH) is providing one-time funding to OMH-licensed, designated, or funded programs to improve the implementation and sustainability of evidence-based care, specifically through the Managing and Adapting Practice (MAP) model.

Program Details:

Participating agencies are eligible for a one-time reimbursement of a minimum of $5,000 per group of three staff completing EBTDC MAP training in the following configurations:

One Supervisor + Two Clinicians (if there is not already a MAP-trained supervisor in your program)
Three Clinicians (if there is already a MAP-trained supervisor in your program)

For each additional trainee beyond the initial three, an extra $1,000 will be granted, up to a maximum of five additional trainees or an additional $5,000.

MAP Funding Requirements:

To qualify for funding, staff attending MAP training must meet specific criteria:

Provide direct clinical services
Carry a caseload that includes at least 3 children or adolescents
Frequently treat childhood anxiety, depression, trauma, and/or disruptive behavior disorder OR supervise clinicians who meet these criteria and are also participating in MAP training
Complete the full MAP training program for 4-5 months as outlined below

MAP training requires a significant time commitment. Participants must complete the following:

Attend 5 full days of webinar-based training.
Engage in at least 6 out of 8 bi-weekly webinar consultations over 4 months.
Submit certification materials at the end of the 5-month period with a passing score to qualify for certification.

Post-Training Requirements:

In addition to training, MAP participants must complete follow-up surveys at 6 and 12 months to assess the integration and continued use of MAP post-certification.

MAP Training Timeline:

This is a time intensive training.

It begins at the 5-day training and ends when you complete your NYS MAP certification materials 4-5 months later. Please take a moment to review the above training timeline and reach out to Nicole.Wang@nyulangone.org with any questions.

44 Holland Avenue, Albany NY 12229 | omh.ny.gov

Managing and Adapting Practice (MAP):

Evidence-Based Practices in OMH-Licensed Community-Based Provider Agencies to Serve Children with Significant Mental Health Needs and their Families

Attestation

Program Details:

Participating agencies are eligible for a one-time reimbursement of a minimum of $5,000 per group of three staff completing EBTDC MAP training in the following configurations:

One Supervisor + Two Clinicians (if there is not already a MAP-trained supervisor in your program)
Three Clinicians (if there is already a MAP-trained supervisor in your program)

For each additional trainee beyond the initial three, an extra $1,000 will be granted, up to a maximum of five additional trainees or an additional $5,000.

MAP Funding Requirements:

To qualify for funding, staff attending MAP training must meet specific criteria:

Provide direct clinical services
Carry a caseload that includes at least 3 children or adolescents
Frequently treat childhood anxiety, depression, trauma, and/or disruptive behavior disorder OR supervise clinicians who meet these criteria and are also participating in MAP training
Complete the full MAP training program for 4-5 months as outlined below

MAP training requires a significant time commitment. Participants must complete the following:

Attend Mandatory Pre-Training Webinar
Attend 4 full days of webinar-based training.
Engage in at least 6 out of 8 bi-weekly webinar consultations over 4 months.
Attend Mandatory Mid-Point Webinar
Submit certification materials at the end of the 5-month period with a passing score to qualify for certification.

MAP Training Timeline:

This is a time intensive training.

44 Holland Avenue, Albany NY 12229 | omh.ny.gov

Attachment:2024 MAP funds Guidelines Attestation_PW training 7.31.24.pdf

I attest to understanding and agree to all the required components of participation:

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Full Name (First & Last):

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Signature:

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Date:

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M-D-Y

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