• 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 may be eligible 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 managed by Alliance Health.

    To learn more about CFAC, visit AllianceHealthPlan.org/about/alliance-health-consumer-and-family-advisory-committee-cfac.

  • Applicant information

  • Date (mm/dd/yyyy)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Is this a cell phone?*

  • Demographic information (confidential)

  • Select your preferred pronouns:
  • Ethnicity:*
  • Race (choose all that apply):*
  • Age:*
  • Shirt Size:*

  • Connection to MH/IDD/SUD/TBI community

  • I am:*
  • Date of birth (mm/dd/yyyy)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Member date of birth (mm/dd/yyyy)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Which disability category or categories is representative of your relationship to Alliance? Please check all 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?*

  • Connection to MH/IDD/SUD/TBI community

    Continued
  • I do hereby attest that this information is true, accurate, and complete to the best of my knowledge.
  • Date (mm/dd/yyyy)*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Thank you for your interest!

    After your application is reviewed, someone from Alliance Health will contact you about next steps.

  •  
  • Should be Empty: