Which community do you live in?
Which of the following age categories do you fall into?
What is your preferred language? What Languages do you speak? Please check all that apply..
Which of the following best describes you? Please check all that apply.
I have lived experience with mental health and/or addictions... *
Which CMHA Champlain East programs or services do you, your family, or the person you care for have experience with? Please check all that apply.
Intensive Case Management Services *
Without sharing any personal health information, briefly describe your experience with CMHA Champlain East and the mental health and/or addictions health services and what unique perspective you would bring to the CMHA Champlain East Client & Caregiver Advisory Council (CFCAC).
Please indicate your level of commitment in the following areas.
I am passionate about enhancing the client experience *
I am in a healthy place in my own recovery and can actively contribute.
I am open-minded and have a positive attitude.
I am comfortable speaking in front of others.
I am comfortable speaking with others about the mental health and/or addictions services, programs and/or care I accessed as part of my own.
Please indicate your experience in the following areas. If "Yes" please provide a brief description fo your background and experience.
Sitting on a formal or informal advisory council or committee
Leading a group or committee (e.g., parent-teacher association).
Specialised areas of expertise (e.g., process improvment, qality, education, strategic planning, communications, marketing)
Working within the health care sector (e.g., mental health, addictions, children& youth, seniors, complex care, long-term care, or work within a community agency). (e.g., process improvment, qality, education, strategic planning, communications, marketing)
Please let us know if you require any specific accommodation needs in order to participate on the Committee. If you prefer to discuss this with someone, we can contact you directly - please let us know below when is best to reach you.
Which of the following times are you abailable to attend in-person quarterly meetings? *
Please let us know if you have access to the following: *
Inaddition to completing the form, you may also upload a current resume and cover letter for consideration.
