Application for the LRS Ohio PAIMI Advisory Council

Please complete this online form to apply to become a member of the LRS Ohio PAIMI Advisory Council. Please do not include any personally identifying information in your answers, for example your Social Security number or date of birth.

Name: *

Address: *

City: *

State: *

Zip code: *

Home phone:

Cell phone:

Work phone:

List practical and/or personal experience with the mental health system:

List present and last employment. Also include volunteer positions:

List organizational memberships and/or associations, especially those in the mental health field:

List education and training, both formal and informal in the mental health, legal and advocacy areas:

Which category are you BEST qualified to represent (choose one):

Attorney

Mental health professional

Provider of mental health services

Individual who has received or is receiving services

Family member

Knowledgeable individual about people who are labeled mentally ill

Which categories are you also qualified to represent (choose all that apply):

Attorney

Mental health professional

Provider of mental health services

Individual who has received or is receiving services

Family member

Knowledgeable individual about people who are labeled mentally ill

If necessary, would you be able to travel to be interviewed at a PAIMI Council meeting? Travel expenses will be reimbursed:

Yes

No

Answer the following: I want to be considered for appointment to the Ohio PAIMI Advisory Council because: *