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Prenatal to 25 Behavioral Health Strategic Plan Advisory Group (SPAG)
Parent/Caregiver 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.)
Parent or guardian of a youth under the age of 13 years old facing behavioral health challenges
Parent or guardian of a young person (13-25 years old) facing behavioral health challenges.
Other – Please Describe
7.
What is the current age of your child/youth?
8.
How old were your child(ren)/youth when they received mental health and drug/alcohol services or supports – and/or the ages they were when you tried to get services for them and were unable to find appropriate care?
9.
Are you employed by, or do you represent, an organization focused on education, behavioral health, or another related field?
Yes
No
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?
11.
Are you an individual whose child/adolescent family member has received behavioral health services?
Yes
No
12.
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
No
13.
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.
14.
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)
15.
Please describe your gender identity (check any that apply):
Female
Male
Non-binary/Gender X
Transgender
Prefer not to answer
Write in (please specify)
16.
Please describe your sexual orientation (check any that apply):
Heterosexual
LGBTQIA+
Prefer not to answer
Other description - Write In
17.
Please describe your disability status:
Person with a disability
Person without a disability
Prefer not to answer
Other - Write In