Alliance Health Consumer and Family Advisory Committee (CFAC) Application

  • Alliance Health Consumer and Family Advisory Committee (CFAC) Application

  • Alliance CFAC promotes a community-based support system that seeks to have each person reach his or her full potential. This committee of individuals and family members gives voice to the interests and opinions of persons with needs related to mental health, intellectual and developmental disabilities, traumatic brain injury, and substance use. It embraces the dignity of all residents in our communities so that each person may achieve his or her highest level of responsibility in the community. It promotes the empowerment of individuals and the active involvement of family members.

    Adult individuals are qualified to be advisory members of the committee if they or a member of their family is a consumer of mental health, intellectual and developmental disabilities, substance use disorder, or traumatic brain injury services.

  • General information

  • Date (mm/dd/yyyy)
     / /
  • Format: (000) 000-0000.
  • Is this a cell phone?*

  • Demographic information

    (confidential)
  • How do you define your gender identity?*
  • What pronouns do you want people to use to describe you?*
  • Ethnicity*
  • Race (Choose all that apply)*

  • Connection to MH/DD/SUD community

  • I am*
  • Which disability category do you identify with for representation? (Please checkall that apply.)*
  • Do you have transportation?*
  • Do you need any special accommodations to attend meetings virtually or in person?*
  • Do you have any dietary restrictions?*
  • How did you hear about CFAC?*
  • Do you work directly for or contract with any of the following?*

  • I do hereby attest that this information is true, accurate, and complete to the best
    of my knowledge.

  • Are you a person with lived experience or a family member?
  •  
  • Should be Empty: