Apply for Membership:
Mental Health Advisory Council

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you willing to serve a four-year term? *

Yes

No

Are you willing to attend at least 6 meetings per year and to advise the Board of Directors with respect to service and priorities? *

Yes

No

Are you willing to sign the Disability Rights Oregon Confidentiality Statement? *

Yes

No

Support the Mission *

Disability Rights Oregon promotes and protects the rights of people with disabilities, including people with mental illness. Will you fully embrace and support this mission and the purpose of the Council?

Yes

No

Please indicate which category you belong to. *

The Council must include members from the following categories. In addition, at least 60% of the Council members must be people who have received mental health services, are receiving mental health services, or are family members of such individuals.

Person who has received or is receiving mental health services

Family member of a person receiving mental health services

Family member of a minor who is receiving or has received mental health services

Attorney

Mental Health Professional

Advocate for people with mental illness

Other

Mental Health Professionals

If you are a mental health professional, identify which type.

Social Worker

Psychologist

Psychiatric Nurse

Psychiatrist

Psychiatric Nurse Practitioner

Peer Support Specialist

Other Mental Health Professional

Oregon Resident *

Are you a resident of Oregon?

Yes

No

Region of Oregon *

What region of Oregon do you live in?

Portland Metropolitan (Clackamas, Multnomah, and Washington Counties)

North Coastal Region (Columbia, Clatsop, Tillamook, and Yamhill Counties)

Central Coast and Willamette Valley Region (Lincoln, Benton, Polk, Marion, Linn, and Lane Counties)

South Coast Region (Coos, Curry, Douglas, Jackson, Josephine, Klamath, and Lake Counties)

Central Oregon (Crook, Deschutes, Hood River, Jefferson, Sherman, and Wasco Counties)

Eastern Oregon (Baker, Grant, Gilliam, Harney, Malheur, Morrow, Umatilla, Union, Wallowa, and Wheeler Counties)