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PAIMI Council Application

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Tell us about yourself.
Name * Required
First Last
Address * Required
Street Address Address Line 2 City State ZIP Code
Phone Number * Required
Email * Required
Briefly describe why you would like to serve on the PAIMI Advisory Council. * Required
If selected, how do you feel you could contribute to the success of the PAIMI Advisory Council? (Briefly describe skills and experience) * Required
The PAIMI Advisory Council is committed to diversity, equity, and inclusion. How has your background and experiences prepared you to be an effective member of the Council? (Examples include any groups you may be a part of or activities you participate in focused on acceptance and awareness of all) * Required
The PAIMI Advisory Council is made up of members who have a variety of connections to mental health. Please check off the connections that apply to you. (Check all that apply)
- I receive/used to receive mental health services
- I am the family member of a person who receives/used to receive mental health services
- I am the family member of a minor child or youth (under 18 years old) who is receiving/has received mental health service
- I am a mental health service provider
- I am a mental health professional
- I am an attorney
- I am an individual knowledgeable about mental illness
Will you be able to commit to attending and actively participating in the quarterly PAIMI Advisory Council meetings?
- Yes
- No
Submitted applications are shared with, and reviewed by, the PAIMI Advisory Council for consideration of nomination. You agree that you can participate at least 4-6 hours a quarter and that you do not have any conflict-of-interest in participating on the PAIMI Advisory Council.
Signature
Date
MM slash DD slash YYYY
In addition to your interest in the PAIMI Advisory Council, would you like to be a volunteer to assist the dLCV in various ways that match your skills and interests?
- Yes
- No
- I'd like to learn more

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PAIMI Council Application

Tell us about yourself.