BHWET-ENC Professional Track Application

Behavioral Health Workforce Education and Training (BHWET) East Montana Professional Track Program

Thank you for your interest in the BHWET East Professional Track Program. Please answer all questions. Partial applications will not be accepted. Submit your application by: September 15, 2023 at 11:59 PM

If selected to be part of the BHWET Professional Track, you will be required to participate in additional learning activities beyond your traditional program requirements. Examples may include additional elective coursework, certification courses, live virtual seminars, and enrollment in the Area Health Education Center (AHEC) Scholars Program. By submitting this application, you acknowledge and agree to fully participate in these additional activities. Failure to participate in all required activities may result in removal from the program.

First name:

Last name:

School Email Address:

Personal Email Address:

Preferred Phone Number:

Preferred Mailing Address Include city, state, and zip code):

Student ID (GID), starts with a dash (i.e. -012345) if applicable:

National Provider Identification (NPI) Number. If you do not have this yet, please leave blank.

Birthdate (mm/yyyy):