CFAC Membership Application

**** All information in this section marked with an asterisk is REQUIRED ****

General Information

Name*

Home Address*

County*

City*

State*

Zip Code*

Home Phone*

Work Phone

Fax

Email Address*

**** All requested information below this point is REQUIRED ****

Membership Requirements

It is important that the membership of the Consumer/Family Advisory Committee be representative of all people in our community. Providing this information helps us to make sure this happens. Please check the areas that describe you.

Service Represented*

Gender

Ethnic Group (Check all that apply)*

Caucasian
African American
Native American
Asian
Hispanic/Latino
Other

Membership Category*

If you have selected Family Member as your Membership Category, please indicate your relationship to the consumer and whether the consumer is an Adult or Youth (under 18).

Relationship to Consumer*

Represent Adult Consumer
Represent Youth Consumer (under 18)

Additional Information

The Vaya Health CFAC currently meets as outlined on the attached schedule.

I am available to meet with the Consumer and Family Advisory Committee on the designated dates and times.*

Yes
No

I have means of transportation.*

Yes
No

I will need assistance with child / adult care.*

Yes
No

I am willing to have my name placed on the CFAC prospective member list.*

Yes
No

Responsibilities

Membership on the CFAC requires a significant commitment of time and energy. Participation involves attending monthly meetings and occasional subcommittee meetings. No special knowledge or training is required to serve on the committee, just a desire to improve the system. Additional reading on topics related to mental health, developmental disabilities and substance abuse issues is required. This material will be provided.

I am committed to partnering with Vaya Health to ensure high quality services for all consumers of behavioral healthcare services.*

Yes
No

I am committed to attending monthly CFAC meetings lasting from 2 to 3 hours.*

Yes
No

I am committed to reading materials that are provided.*

Yes
No

I understand that attendance to CFAC meetings is mandatory. In the event that I am unable to attend, I am responsible to inform the Chair or the Liaison as soon as possible prior to the meeting.*

Yes
No

I understand that my participation in public activities of the CFAC may identify me as a consumer or a family member of a consumer of Mental Health, Intellectual/Developmental Disabilities and/or Substance Use Disorder services.*

Yes
No

Please share your reasons for wanting to become a CFAC Member*

The information on this application will be used by the Consumer and Family Advisory Committee for the selection of its members based on state requirements to maintain a committee representative of consumers and family members of consumers receiving MH/IDD/SAS behavioral healthcare services. The confidentiality of individuals applying for membership will be respected and protected.

General Information

Membership Requirements

Additional Information

Responsibilities

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CFAC Membership Application

General Information

Membership Requirements

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Responsibilities

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