Mental Health Services Act (MHSA) STEERING COMMITTEE MEMBER APPLICATION Date: Name: Title: Organization Agency Affiliation: or Address: Phone #: E-mail: Which stakeholder representative seat are you applying for (select ONE)? Client/Consumers of behavioral health services (youth, transition-age youth) Client/Consumers of behavioral health services (adults, older adults) Families of clients/consumers of behavioral health services Providers of mental health and substance use services Providers of social services Cultural competence and diversity Disabilities Education Health care Law enforcement Veterans and /or representatives from veterans organizations Other interests (faith-based, aging and adult services, youth advocacy, individuals served by MHSA programs, etc.) Age: <15 years 16-25 years 26-59 years 60+ years Decline to state What is your preferred language? (select ONE) English Spanish Cantonese/Mandarin Tagalog Other: ____________ Race: American Indian/Alaska Native Asian African-American/Black Caucasian/ White Native Hawaiian Other Pacific Islander Other: ____________ Decline to state
Mental Health Services Act (MHSA) STEERING COMMITTEE MEMBER APPLICATION Date: Name: Title: Organization or Agency Affiliation: Address: Phone #: E-mail: Which stakeholder representative seat are you applying for (select ONE)? Client/Consumers of behavioral health services (youth, transition-age youth) Client/Consumers of behavioral health services (adults, older adults) Families of clients/consumers of behavioral health services Providers of mental health and substance use services Providers of social services Cultural competence and diversity Disabilities Education Health care Law enforcement Veterans and /or representatives from veterans organizations Other interests (faith-based, aging and adult services, youth advocacy, individuals served by MHSA programs, etc.) Age: <15 years 16-25 years 26-59 years 60+ years Decline to state What is your preferred language? (select ONE) English Spanish Cantonese/Mandarin Tagalog Other: ____________ Race: American Indian/Alaska Native Asian African-American/Black Caucasian/ White Native Hawaiian Other Pacific Islander Other: ____________ Decline to state