MN Prairie County Alliance Membership Form

LAC (Local Advisory Council) - MEMBERSHIP FORM

The MN Prairie County Alliance Adult Mental Health Local Advisory Council offers individuals, parents, and mental health service providers the opportunity to make a difference in how mental health care is provided in the community. If you are interested in using your experience and knowledge to help create a better adult mental health care system, please complete the following form.
You may fill out this form and then click on Submit (at the bottom of the form).

To get a printed copy of the form (either before or after filling it out), click on Print at the bottom .

The address to mail the form in is listed at the bottom.
Contact Information

Please complete the fields below
Name*

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Email*
example@example.com
I'm a person with lived experience with a mental health conditionI'm a family member of an adult with a mental health condition.I'm a mental health professional or practioner.
Eligibility

Please complete to finalize the form - Thank you
Dodge CountySteele CountyWaseca Couinty
YesNo
Signature*
Date*

MonthDayYear
Mail form to:

NAMI Southeast Minnesota

2746 Superior DR NW, STE 110

Rochester, MN 55901
Should be Empty: