Disability Rights Ohio - PAIMI Application

* indicates required information

* Name:

* Street Address:

* City:

* State:

Must live in Ohio to be on the PAIMI Advisory Council.

* Zip Code:

* County of Residence:

Mailing Address, if different:

City:

State:

Zip Code:

* Email Address:

Cell Phone:

Home Phone:

Work Phone:

* Please check which of the following apply to you (check all that apply):

Attorney

Mental health professional

Provider of mental health services

Individual who has received or is receiving mental health services

Family member of a person who has received or is receiving mental health services

Parent of a minor child who has received or is receiving mental health services

Knowledgeable individual about people who are labeled mentally ill

* Of the above categories checked, please specify what you consider to be your primary category:

Attorney

Mental health professional

Provider of mental health services

Individual who has received or is receiving mental health services

Family member of a person who has received or is receiving mental health services

Parent of a minor child who has received or is receiving mental health services

Knowledgeable individual about people who are labeled mentally ill

* Do you identify as having a disability(ies) or mental health label?

If you would like to disclose more, you can do so here:

* List practical and/or personal experience with the mental health system that you have:

* What is your current occupation/employer?

* List volunteer positions/experience:

* Are you a current board member of advisory council for a provider of mental health services?YesNo

If yes, which agency/organization?

* List board, council, or other task group experience and your role or accomplishments in the groups

* 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:

* If necessary, would you be able to travel to PAIMI Council meetings? Eligible 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.YesNo

* What opportunities have you already had to help improve mental health-related services?

* What are your top 3 reasons you want to serve on the Ohio PAIMI Advisory Council?

* What skills, talents, experiences or education do you have that would help the Council in their activities?

* Please describe any self-advocacy you have engaged in, and/or advocacy you have done related to mental health and/or people receiving mental health supports:

* Priorities for the PAC program includes advancing the rights of people with mental illness and supporting empowerment and recovery. Please describe why advocacy specific to persons with a psychiatric disability is important to you.

* Currently the PAC meets 4 times a year either virtually or at the Disability Rights Ohio office in Columbus. Would you be able to participate in our PAC meetings in person or virtually?

In person

Virtually

* Participation in the Council's committees is primary to ensure that the work of the Council continues. Would you be able to participate in 1 or 2 committees each month? Meetings usually last 1 hour and take place over Zoom. Committees set their own meeting times and all meet after 5 p.m.YesNo

Internal Comments:

For internal use only

By submitting this application, you understand and approve that all the information in the application and your 3 recommendations letters will be shared with the Nominating Committee and PAIMI Advisory Council to determine if you would be a good match for currently open seats on the PAIMI Advisory Council. Before a candidate is selected for appointment to the PAC, they will go through an interview with the PAC. After interview, the PAC interview team will then make a recommendation regarding appointment.

PAIMI Application

PAIMI Application

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