MHSA Steering Committee Application

The MHSA Steering Committee meets twice a year. As we begin the Three-Year Planning Phase in January 2017 there may be 1-2 additional meetings to allow for more engagement and making recommendations. Please review the MHSA Steering Committee Roles and Responsibilities document for more information.

Question Title

* 1. Personal Information

First Name

Last Name

Title

Organization or Agency Affiliation

Question Title

* 2. Contact Information

Address

City/Town

Email Address

Phone Number

Question Title

* 3. As an MHSA Steering Committee member, which of the following stakeholder group would you want to represent? (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.)

Other (please specify)

Question Title

* 4. Would you be interested in participating in a smaller MHSA Membership Selection Group?
The Membership Selection Group would meet twice a year to review any membership applications submitted and make recommendations for appointments to the Steering Committee.

Yes

Question Title

* 1. Personal Information

Question Title

* 2. Contact Information

Question Title

* 3. As an MHSA Steering Committee member, which of the following stakeholder group would you want to represent? (Select ONE)

Question Title

* 4. Would you be interested in participating in a smaller MHSA Membership Selection Group? The Membership Selection Group would meet twice a year to review any membership applications submitted and make recommendations for appointments to the Steering Committee.

* 4. Would you be interested in participating in a smaller MHSA Membership Selection Group?
The Membership Selection Group would meet twice a year to review any membership applications submitted and make recommendations for appointments to the Steering Committee.