Protection and Advocacy for Individuals with Mental Illness (PAIMI) Advisory Council Application

Do you have a disability?*

YesNo

Please specify disability:

Are you a parent of a person with disability?*

YesNo

Please specify disability and age of individual:

What experience have you had with people with disabilities and/or families of people with disabilities?*

What experiences have you had serving on community boards, advisory councils, or committees?*

Would you commit to attending quarterly Disability Rights Arkansas PAIMI Advisory Council meetings of approximately four hours on Saturdays in Little Rock? (Mileage can be reimbursed or donated to the organization).*

YesNo

What is your major interest in serving on the PAIMI Advisory Council of Disability Rights Arkansas?*

Why do you think you would make a good candidate for this advisory council?*

Federal Law requires the PAIMI Advisory Council to be comprised of individuals from different backgrounds. We are required to ask the following information to ensure federal compliance.

Of the following, please check all that currently apply to you:

I am currently receiving or have previously received mental health services.I am the family member of an individual who currently receives or has previously received mental health services.I am a family member and primary care giver for a minor child or youth (under 18 years old) who has received or is receiving mental health services.I am a licensed mental health professional.I am a licensed attorney.I am an individual from the public who is knowledgeable about mental illness, the advocacy needs of persons with mental illness, and who has demonstrated a substantial commitment to improving mental health services.

Protection and Advocacy for Individuals with Mental Illness (PAIMI) Advisory Council Application

Demographics