CBH Member Advisory Council Application

CBH Member Advisory Council Application

The Community Behavioral Health (CBH) Member Advisory Council (MAC) was created in response to the organization’s commitment to support its Members through culturally responsive practices.

To learn more, visit the MAC webpage at cbhphilly.org.

Confidentiality Statement:

Participants will be required to adhere to CBH’s confidentiality standards and will be required to sign a confidentiality agreement. Additionally, all personal information collected on this form will be kept confidential and will not be shared.

Please contact Noelle Ciara at Noelle.Ciara@phila.gov with any questions.

Full Name:*

Phone:*

Email:*

Preferred Contact Method:*

Select

ZIP Code:*

Age:*

What are your preferred gender pronouns?*

Select

If you chose "Other," please let us know your preferred gender pronouns here.

Race or Ethnicity:*

Select

Primary Language Spoken:*

Do you require interpretation services?

Select

CBH Membership Affiliation:*

Select

If other for affiliation, please explain:

What is/are your reason(s) for wanting to be a part of the CBH MAC?*

How do you see yourself contributing to building a culturally responsive council?*

Do you think you would need accommodations to participate?*

Select

If yes, what do you need?

Can you commit to a one-hour meeting each quarter (3 months)?*

Select

Do you participate in any other community-based groups?*

Select

If yes, please briefly describe:

Can CBH reach out for other feedback opportunities*

Select or enter value

Date Submitted:*

Send me a copy of my responses

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