Client Advisory Board Application

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What is the purpose of a Client Advisory Board?

To have a group of approximately 7-12 clients responsible for holding Health Emergency Lifeline Programs (HELP) accountable to fulfilling their mission and providing quality services. The CAB will evaluate the services provided by HELP and respond to clients’ suggestions and concerns about the services that they receive.

Qualifications: You must currently receive, or have received services at HELP in the past. You must be able to attend a late afternoon/evening meeting on the third Tuesday of the month at HELP. We are asking for at least a one year commitment.

Incentives: You will be provided with a meal, bus tickets or compensation for gas, and the good feeling from advocating for clients and improving the services at HELP. There will also be opportunities for various trainings and skill building activities.
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Directions: Please answer the following questions in detail, as your responses will help to ensure that we have a diverse group of board members who will provide a wealth of experience and wisdom.
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Name* This field is required.Please type your name below.
First Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Phone Number* This field is required.
Area Code
Phone Number
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Email
example@example.com
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Are you currently receiving services at HELP?* This field is required.
Please Select
Please Select
Yes
No
Please select the appropriate response from the dropdown list.
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If so, which services?
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If not currently receiving services, when did you last receive services? Which services?Please type the year of most recent services received and service description.
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Briefly describe your experiences at HELP. (Please be as honest as possible. Critical comments may even be beneficial for your application getting chosen.)* This field is required.
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Have you ever been part of a Client Advisory Board (workgroup, board, committee, etc.)? This is NOT a requirement* This field is required.
Please select the appropriate response from the drop down list.
Please select the appropriate response from the drop down list.
YES
NO
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If yes, please list.
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What interests you most about being part of the Client Advisory Board?* This field is required.
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What experiences do you have that will be helpful to the Client Advisory Board? * This field is required.
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6. Check all services that you are familiar with at HELP.* This field is required.
Please select any applicable services.
Medical Case Management
Behavioral Health Services
Emergency Financial Assistance
Non-Medical Case Management
Insurance Assistance
Tobacco Cessation
HIV Primary Care
Early Intervention Services
Medical Nutritional Therapy
Food Bank
Housing Services
PrEP & Prevention Services
Keep It Movin' Fitness and Nutrition Services
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How comfortable are you using technology for electronic communications and virtual conference meetings? (This will not be counted against you. Training and support will be made available for participation. )* This field is required.
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8. How do you define you Race/Ethnicity?
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9. How do you define your gender?
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10. How do you define your sexual identity?
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11. Age:
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12. Anything else you want to tell us about yourself (e.g., employment, interests, etc.)?
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Please complete this application and a CAB member will be calling you soon. If you have not been reached after 21 days, contact a staff liaison by calling Corktown Health Center at 313-832-3300 and ask to be transferred. Thank you so much for your interest in joining the CAB!
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