The mission of the ACA Foundation (ACAF) is to advance mental health and well-being through advocacy, community, inclusion and research.

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* 1. Name

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* 2. What state do you reside in?

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* 3. Email address

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* 4. Preferred Phone#

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* 5. ACA Membership #

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* 6. ACA Membership Class (Professional, Student, Retired, etc.)

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* 7. Education and Licensure

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* 8. Institute(s) of Higher Education and Graduation Dates

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* 9. Are you a licensed professional counselor?

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* 10. Nomination Source

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* 11. Qualifications / Statement - Describe why you are nominating yourself or another member to this position. Please upload an executive summary providing details on the nominees qualifications and skills.

For reference, the desired competencies include the following: a visionary leader, finance and fundraising experience, an understanding of non-profits, and personal and/or professional investment in the ACA Foundation.

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* 12. Leadership experience - List up to five leadership roles or volunteer activities that speak to the individuals qualifications and/or prior service to ACA

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