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Advisory Council Membership Application

Please fill-up the online form then submit or you may download the Council Application and mail to MHSA Advisory Council, 1340 Arnold Drive, Suite 200, Martinez, CA 94553.

Online Membership Application Form

 Area Code first
Please check all characteristics or affiliations that apply to you:
a. I live in:
b. I work in:
c. I am:  
A current consumer of:
A past consumer of:
A family member of a child or transition age youth:
A family member of an adult consumer:
d. I have paid or volunteer experience in:
e. I am affiliated with or representing:
f. OPTIONAL: With what racial, ethnic or cultural group(s) do you identify? (Check all that apply):
c. With which part(s) of the county do you mostly identify?
NOTE: If you are selected, your agency affiliation and/or selected characteristics may become public information.