Arizona Behavioral Health Planning Council Membership Application

Candidate's Full Name

Street/PO Box

App. Unit

City

State Arizona

Zip Code

Home (xxx-xxx-xxxx)

Work (xxx-xxx-xxxx)

Cell (xxx-xxx-xxxx)

Agency Name

Street/PO Box

App./Unit

City

State Arizona

Zip Code

Peronal 1

Peronal 2

Work

HomeWork

MaleFemaleOther (please specify)

Caucasian/WhiteAfrican American/BlackHispanic/Latino/LatinaAsian/Pacific IslanderAmerican IndianBi/Multi RacialOther (please specify)

Adult Behavioral Health Recipient
Adult who is in Recovery for Substance Abuse
Adolescent Behavioral Health Recipient
Provider Agency Representative (please specify agency)

Family Member of an Adult living with a Serious Mental Illness
Family Member of a Child (under 18) living with a Serious Emotional Disturbance
Family Member of a Child or Adult who has a history of Substance Abuse
Advocacy Organization (please specify organization)

Arizona Behavioral Health Planning Council Membership Application

Home Address

Telephone Numbers

Work Address

Email Addresses

Correspondence Preference

Gender Identity

Ethnicity

Appointment Categories

1. Please explain your interest in serving on the Arizona Behavioral Health Planning Council.

2. Please explain your knowledge of, or experience with, the Arizona publicly funded Behavioral Health system (may include services received).

3. Please list your experience or qualification for serving on the Planning Council.

AVA