Prenatal to 25 Behavioral Health Strategic Plan Advisory Group (SPAG)

Youth and Young Adult Application

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* 1. Email address:

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* 2. First and Last Name:

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* 3. Phone Number:

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* 4. What city do you live in?

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* 5. Why are you interested in participating in the Strategic Plan Advisory Group?

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* 6. Are you an individual who has received behavioral health services or whose family member has received behavioral health services?

Yes

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* 7. What is your age?

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* 8. What were the age(s) in which you received, tried to get, or needed and didn’t get mental health and/or drug/alcohol-related services or supports?

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* 9. Are you employed by, or do you represent, an organization focused on education, behavioral health, or another related field?

Yes

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* 10. If you answered "yes" to the previous question, please answer the following:

What organization do you work for?
What is your role at the organization?

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* 11. Do you currently serve on any other work groups, task forces, or commissions related to P-12 students in Washington and/or behavioral health services to children and youth?

Yes

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* 12. If yes, please list:

Our goal is to identify subcommittee members who represent the diversity of youth and families, in Washington state. We ask you that you answer a few demographic questions to assist us in doing so. None of your responses to the following demographic questions will be made public. Demographic information will be used solely for the purpose of understanding the degree to which the applicant pool, and subsequently subcommittee membership, are representative of the communities the subcommittee seeks to represent.

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* 13. Please describe your racial and ethnic identity (check any that apply):

American Indian/Alaska Native

Asian

Black/African American

Hispanic/Latinx

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Write in (please specify)

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* 14. Please describe your gender identity (check any that apply):

Female

Male

Non-binary/Gender X

Transgender

Prefer not to answer

Write in (please specify)

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* 15. Please describe your sexual orientation (check any that apply):

Heterosexual

LGBTQIA+

Prefer not to answer

Other description - Write In

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* 16. Please describe your disability status:

Person with a disability

Person without a disability

Prefer not to answer

Other - Write In

Prenatal to 25 Behavioral Health Strategic Plan Advisory Group (SPAG)

Youth and Young Adult Application

Question Title

* 1. Email address:

Question Title

* 2. First and Last Name:

Question Title

* 3. Phone Number:

Question Title

* 4. What city do you live in?

Question Title

* 5. Why are you interested in participating in the Strategic Plan Advisory Group?

Question Title

* 6. Are you an individual who has received behavioral health services or whose family member has received behavioral health services?

Question Title

* 7. What is your age?

Question Title

* 8. What were the age(s) in which you received, tried to get, or needed and didn’t get mental health and/or drug/alcohol-related services or supports?

Question Title

* 9. Are you employed by, or do you represent, an organization focused on education, behavioral health, or another related field?

Question Title

* 10. If you answered "yes" to the previous question, please answer the following:What organization do you work for? What is your role at the organization?

Question Title

* 11. Do you currently serve on any other work groups, task forces, or commissions related to P-12 students in Washington and/or behavioral health services to children and youth?

Question Title

* 12. If yes, please list:

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* 13. Please describe your racial and ethnic identity (check any that apply):

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* 14. Please describe your gender identity (check any that apply):

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* 15. Please describe your sexual orientation (check any that apply):

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* 16. Please describe your disability status:

* 10. If you answered "yes" to the previous question, please answer the following:

What organization do you work for?
What is your role at the organization?