Disability Rights Ohio - PAIMI Application

* List organizational memberships and/or associations, especially those in the mental health field:

* List education and training, both formal and informal in the mental health, legal and advocacy areas:

* Which category are you BEST qualified to represent (choose one)?

Attorney

Mental health professional

Provider of mental health services

Individual who has received or is receiving services

Family member

Knowledgeable individual about people who are labeled mentally ill

* Which categories are you also qualified to represent (choose all that apply)?

Attorney

Mental health professional

Provider of mental health services

Individual who has received or is receiving services

Family member

Knowledgeable individual about people who are labeled mentally ill

* If necessary, would you be able to travel to be interviewed at a PAIMI Council meeting? Travel expenses will be reimbursed, but we encourage you to notify Disability Rights Ohio if pre-paying your expenses is a barrier to your participation.

* Answer the following: I want to be considered for appointment to the Ohio PAIMI Advisory Council because:

Internal Comments:

For internal use only

To complete this application, you must submit two letters of recommendation from persons of your choice. How would you like to submit your letters of recommendation?

I will send them by mail to:
Ohio PAIMI Advisory Council
c/o Disability Rights Ohio
200 Civic Center Drive
Columbus, OH 43215-4234

I will fax them to 614-644-1888.

I will email them. Please have a DRO representative contact me to give me the correct email address.

PAIMI Application

PAIMI Application

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