First Name:
Last Name:
Street Address:
City:
Zip Code:
Phone:
Fax:
Email:
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:
(Please describe):
A past consumer of:
(Please describe):
A family member of a child or transition age youth:
(please describe):
A family member of an adult consumer:
(please describe):
(please identify):
d. I have paid or volunteer experience in:
(specify):
(specify):
(specify):
e. I am affiliated with or representing:
(specify):
(specify):
(specify):
(specify):
f. OPTIONAL: With what racial, ethnic or cultural group(s) do you identify? (Check all that apply):
(specify):
2. a. After reviewing all of the above characteristics and/or affiliations that may apply to you, which is the primary perspective or viewpoint that you feel you represent?
b. Which would be the secondary perspective or viewpoint that you feel you represent?
c. With which part(s) of the county do you mostly identify?
3. Why are you interested in participating in the MHSA Advisory Council?
4. Please describe the knowledge and/or experience that you have providing or receiving mental health services that you could bring to the MHSA Advisory Council.
5. Please describe the knowledge and expertise that you could bring in the area of the needs and resources of the diverse cultures that comprise Contra Costa County.
6. Please describe any other knowledge or expertise that you could bring to this Advisory Council.
7. Can you commit to attending meetings every other month on the first Thursday of that month from 3:00 P.M. to 4:30 P.M.?
8. Can you commit to participating in at least one additional Contra Costa Behavioral Health sub-committee, such as Suicide Prevention Coalition, Elder Wellness and Advocacy Coalition, Adult Behavioral Health Care Partnership, Reducing Health Disparities, Innovation/System of Care, Housing, Social Inclusion, Membership or Steering?
9. Is there anything else that you feel want to share?
10. Do you have any special needs or require reasonable accommodation in order to participate?
NOTE: If you are selected, your agency affiliation and/or selected characteristics may become public information.
