Behavioral Health Advisory Committee Application

Optional - Print Application

Download and Print the Application: https://www.piercecountywa.gov/3035/Application or continue filling out the online application below.

Name

Which of the following locations is most relevant to this appointment?

Address

Residential Street Address NOT a PO Box

City, State, Zip

What is the ownership status of your place of residence?

Home Phone

Cell Phone

Work Phone

Email Address

Date of Birth

mm/dd/yyyy

Are you a representative from any of the following organizations/communities?

Please select all that apply:

Law Enforcement / First Responder

Criminal Justice / Therapeutic Court

Mental Health / Chemical Dependency Services Provider

Youth Treatment Provider

Hospital System

Evaluation and Treatment / Withdrawal Management Provider

Behavioral Health Navigator or Peer Advocate

Homeless / Supportive Housing Provider

Veterans Services Provider

Organization with experience developing or implementing the Pierce County Accountable Care Organization

Organization or individual advocating for persons experiencing behavioral health challenges / Persons with lived experience navigating the behavioral health system

Other:

Please specify which organization/community group:

Occupation and Employer

If retired, please indicate “Retired” with your former employer and occupation:

What is the highest degree or level of school you have completed?

Education

Name of high school, college/university, degree:

Professional/Community Activities

Describe your interest in serving:

Describe qualifications that would make you successful in this position:

If you chose one area for behavioral health system improvement in Pierce County, what would it be and why?

Membership on the Advisory Committee will require monthly attendance. Can you meet the attendance requirements for serving on this committee with or without an accommodation?

The Advisory Committee Board will consist of staggered memberships to ensure continuity. Initial members may be appointed to terms of one, two or three years. Please indicate your preference for initial term of membership.

One

Two

Three

Are you, your spouse, or a member of your immediate family an employee of Pierce County?

Are you currently serving on any other Pierce County Boards or Commissions?

Personal Reference #1 Name

Personal Reference #1 Occupation

Personal Reference #1 Address

Personal Reference #1 Phone

Personal Reference #2 Name

Personal Reference #2 Occupation

Personal Reference #2 Address

Personal Reference #2 Phone

Personal Reference #3 Name

Personal Reference #3 Occupation

Personal Reference #3 Address

Personal Reference #3 Phone

Digital Signature

Send me a copy of my responses

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