CFAC Membership Application

Thank you for your interest in joining the Vaya Health Consumer and Family Advisory Committee (CFAC). The CFAC represents and gives voice to people who receive services for mental health, substance use disorder, intellectual/developmental disabilities (I/DD), or traumatic brain injury (TBI) by providing important input into Vaya’s operations and processes.

A Vaya representative will contact you to follow up on your application. For help, email cfac@vayahealth.com or call 1-800-893-6246 and ask to speak with a CFAC liaison.

General Information

Name(Required)

Home Address(Required)

County of Residence(Required)

City(Required)

State(Required)

Zip Code(Required)

Primary Phone Number(Required)

Email Address(Required)

Demographic Information

Vaya strives to make sure CFAC members are representative of people we serve in our region. Please provide the following information about yourself.

Type of Experience (Check all that apply)(Required)

I have experience with mental health, substance use disorder, I/DD, and/or TBI needs.

I have been a caregiver for a person with mental health, substance use disorder, I/DD, and/or TBI needs.

Area(s) of Lived/Caregiving Experience (Check all that apply)(Required)

Mental health

Substance use disorder

I/DD

TBI

Gender

Preferred Pronouns

Race/Ethnicity (Check all that apply)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Some other race

Prefer not to share

Other race

Responsibilities

CFAC membership includes attending regular meetings and occasional subcommittee meetings. Meetings are held in a hybrid format, with the option to attend in person or virtually from your home computer, smartphone, or other device, and generally last two to three hours. Upcoming meeting dates and times are available on our Calendar of Events.

No special knowledge or training is required to serve on the committee—just a desire to improve services in our local communities.

I understand CFAC members must be adults. I am an adult. (Required)(Required)

Yes

I am committed to partnering with Vaya to strengthen the state’s public system of public health care services.(Required)

Yes

I understand that attendance at CFAC meetings is mandatory. If I am unable to attend a meeting, I am responsible for informing the chairperson or the Vaya CFAC liaison as soon as possible prior to the meeting.(Required)

Yes

I will need an accommodation (such as an interpreter service, auxiliary aid, or service for a person with a disability) to participate in CFAC meetings. (A need for an accommodation will not negatively affect your application.)(Required)

Yes

If you answer yes, a new text field will open to allow you to add your requested accommodation.

You selected yes, please describe the accommodation

I understand my participation in CFAC activities may identify me as an individual who has experienced (or as the caregiver of an individual who has experienced) mental health, substance use disorder, I/DD, and/or TBI needs.(Required)

Yes

Please include any other information you would like to share with the committee.

The Vaya Health Consumer and Family Advisory Committee (CFAC) will use the information provided in this application to select committee members based on North Carolina state requirements to maintain a committee representative of individuals and caregivers of individuals receiving mental health, substance use disorder, I/DD, and/or TBI services. Vaya and the Vaya CFAC will respect and protect the confidentiality of individuals applying for membership.

CAPTCHA