SMHPC Membership Survey

Thank you for being a part of the Massachusetts State Mental Health Planning Council. Your time spent participating is important and appreciated by both the SMHPC and the Department of Mental Health.

One of the primary responsibilities of the Council is review and approve the federal Block Grant each year. The Department needs to report on both department activities and SMHPC activities. We also need to report on membership demographics to ensure there is adequate representation of diverse populations. In order to do that, we're asking people to self-identify in several areas.

This is NOT a requirement to participate. People should only self-identify if they're comfortable doing so. Your name will never be reported to SAMHSA, we only sent total numbers. This survey is done on a HIPAA compliant account. No one will be able to see the self-identified info except for me. Any data I release will be general info (name, contact info, employer, etc.) Anything else will only be used to determine total numbers.

We're asking everyone to complete the beginning portion of the survey so we have a general membership list. Additional information should be completed if you're comfortable.

You'll notice that some of the options are outdated and not used by DMH. Unfortunately that is how we are required to report on the Block Grant. As the language changes there I'll correct it here.

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* 1. First Name

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* 2. Last Name

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* 3. Agency/Affiliation

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* 4. Title

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* 5. Preferred Mailing Address

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* 6. Preferred Telephone Number

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* 7. Preferred Email Address

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* 8. Please check any/all of the following that apply to you (by law, the Council must include representatives from affiliated state agencies, and more than 50% of members must be consumers or family members; however, your response is optional):

State Agency

Provider

Professional/Trade Group

Legislator

Advocate

Certified Peer Specialist

Family Member of an Adult Consumer

Family Member of a Child or Adolescent Consumer

Other

Please answer the following questions if you're comfortable doing so.

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* 9. Do you identify as:

LGBTQ+

Black/African American

Hispanic

Asian/Pacific Islander

Mixed Race

Native Amnerican

Person with Lived Experience/Peer

Veteran

Hearing Impaired

Visually Impaired

Physically Disabled

Currently or Formerly Homeless

Age 50+

Age 16-26

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* 10. Is there an accommodation that would make participating in SMHPC quarterly meetings or sub-committee meeting easier for you? (ASL interpreters, etc.)

SMHPC Membership

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* 1. First Name

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* 2. Last Name

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* 3. Agency/Affiliation

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* 4. Title

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* 5. Preferred Mailing Address

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* 6. Preferred Telephone Number

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* 7. Preferred Email Address

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* 8. Please check any/all of the following that apply to you (by law, the Council must include representatives from affiliated state agencies, and more than 50% of members must be consumers or family members; however, your response is optional):

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* 9. Do you identify as:

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* 10. Is there an accommodation that would make participating in SMHPC quarterly meetings or sub-committee meeting easier for you? (ASL interpreters, etc.)

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* 11. Do you have a particular area of interest concerning mental health services?

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* 12. Anything else you'd like us to tell us?