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Community Mental Health & Substance Abuse Services
Home Address: 
Home City: 
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Home Phone: 
Business Phone: 
Cell Phone: 
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Length of residency in Kalamazoo County: 
How many hours could you commit to the Board per week/month? : 
State law prohibits an individual from being appointed to a community mental health board if he/she is a party to a contract with the community mental health services program or administers or benefits financially from such a contract; or (2) serves in a policy-making position with an agency under contract with the community mental health services program. Listed below is a list of agencies that contract with the Kalamazoo County Community Mental Health Authority Board. This list is not all-inclusive.
   Do any of these restrictions apply to you?

Catholic Family Services
Community Living Options
Family & Children Services
Community Healing Center
Hope Network
InterAct of Michigan
MRC Industries, Inc.
Senior Services
Ministry with Community
Douglass Community Association
Gryphon Place
Housing Resources
Residential Opportunities, Inc.
WMU/Center for Disability Services
Certain categories need to be represented on the Community Mental Health Authority Board. Please check the categories which you believe apply to you:
a. Mental health services provider: 
b. General Public: 
c. Agencies/occupations having a working involvement with mental health services: 
d. Primary consumer: 
(defined as an individual who has received or is receiving services from the private sector equivalent to those offered by the Department or a community mental health services program)
e. Recipient: 
(defined as an individual who is currently directly receiving mental health services from the Department of Community Mental Health, a community mental health services program, or a facility or from a provider that is under contract with the Department or a community mental health services program)
f. Family member: 
(defined as a parent, stepparent, spouse, sibling, child, or grandparent of a primary consumer, or and individual upon whom a primary consumer is dependent for at least 50% of his/her financial support)
If you checked category a, c, d, e or f above, please explain how you represent that category.
What personal or professional experiences have you had with the target populations served by the Community Mental Health Authority Board?
Why do you desire to serve on the Community Mental Health Authority Board?
There is a limit of six "public officials" who can serve on the Community Mental Health Authority Board. "Public officials" are those persons serving in an elected or appointed public office or employed more than 20 hours per week by an agency of federal, state, city or local government. This includes public schools/colleges/universities.
   Are you a public official?
If YES, explain:
List membership on other boards or commissions:
Verification Code:  (This helps prevent automated e-mails.)
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