PAIMI Advisory Council as a Public Member - Online Form Share: PAIMI Advisory Council as a Public Member - Online Form Full Name: Address: City: State Zip: Phone Email: Why do you want to participate on the PAIMI Advisory Council? What will you bring to the PAIMI Advisory Council? What is your vision for the PAIMI Advisory Council? Describe your advocacy experience (advocating for oneself, a family member, or others). Describe your involvement on committees, organizations, conference/trainings, etc. that address mental health issues. Please include the names of committees, organizations, etc. Describe your educational background, current employment and/or other volunteer activities. List at least two references. Please include the name, telephone number and email address for each reference. Additionally, please list if you have a relative who is a DRC staff member or on DRC’s Board of Directors. Our PAIMI Council values diversity. To assist the Committee in selecting diverse Council members, please identify which of the following group(s) you belong to: Decline to State, African American/Black, Asian/Pacific Islander, Hispanic/Latino, Native American, White, Multi-racial; Developmental Disability, Psychiatric Disability, Learning Disability, Sensory Disability, Physical Disability, Other Disability; Gay, Lesbian, Bisexual, Transgender. For PAIMI Advisory Council applications, describe your experience working on issues of importance to mental health consumers, and in what capacity you are a provider of mental health services. For PAC Eligibility, please answer the following: 1. Are you a current or former Mental Health Services Professional? Yes No 2. Are you a current or former Mental Health Service Provider? Yes No 3. Are you a Peer Support Specialist? Yes No 4. Are you an Attorney? Yes No 5. Are you an individual from the public knowledgeable about mental illness? Yes No 6. Are you the primary caregiver of a minor child or youth (under 18 years old) who has received or is receiving mental health services? Yes No
