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Prenatal to 25 Behavioral Health Strategic Plan Advisory Group
System Partner Application
1.
Email address:
2.
First and Last Name:
3.
Phone number:
4.
What city do you live in?
5.
Why are you interested in participating in the Strategic Plan Advisory Group?
6.
What perspective or experience are you bringing to the subcommittee? (You may check more than one option.)
State Agency Representative
Child, Youth/Young Adult, or Parent/Caregiver Service Provider
Managed Care Organization Representative
BH-ASO Representative
Advocate
Tribal Representative
Other – Please Describe
7.
Are you employed by, or do you represent, an organization focused on education, behavioral health, or another related field?
Yes
No
8.
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?
9.
Do you currently serve on any other work groups, task forces, or commissions related to children, youth/young adults, or parents/caregivers in Washington?
Yes
No
10.
If yes, please list:
Our goal is to identify advisory group members who represent the diversity of 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 advisory group membership, are representative of the communities the subcommittee seeks to represent.
11.
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)
12.
Please describe your gender identity (check any that apply):
Female
Male
Non-binary/Gender X
Transgender
Prefer not to answer
Write in (please specify)
13.
Please describe your sexual orientation (check any that apply):
Heterosexual
LGBTQIA+
Prefer not to answer
Other description - Write In
14.
Please describe your disability status:
Person with a disability
Person without a disability
Prefer not to answer
Other - Write In