Fillable CASCADE COUNTY Mental Health Local Advisory Council Application (Cascade County)

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CASCADE COUNTY Mental Health Local Advisory Council Application (Cascade County)

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Boards/Board Applications:MHLAC County Application
CASCADE COUNTY
Mental Health Local Advisory Council
Application
Please complete this form and return it to the County Commission Office, Room 111 Courthouse Annex,
325 2
nd
Avenue North, Great Falls, MT 59401. If you have any questions, please contact the Commission
Office @ (406) 454-6810. This application is designed to obtain information as to your interest and
qualifications for serving on a County Government Board.
---------------------------------------------------------------------------------------------------------------------------------
(Please Print or Type) Date________________________________
NAME________________________________________________________________________________
TELEPHONE (Home)__________(Work)_________(Cell)_________ (E-Mail)_____________________
ADDRESS_____________________________________________________________________________
Current County Boards or Volunteering ___________________________________________________
______________________________________________________________________________________
Previous Public Experience, Boards or Volunteering _________________________________________
______________________________________________________________________________________
Employer_____________________________________________________________________________
Education_____________________________________________________________________________
Please indicate which category you are qualified for.
______ Mental Health Services: Consumer
______ Mental Health Services: Family Member of Consumer
______ Provider: Mental Health Services ____ Adult ____Child
______ Representative: City Attorney, County Attorney or Public Defender
______ Representative: Center for Mental Health
______ Representative: Benefis Health System or Great Falls Clinic Hospital
______ Representative: Community Health Care Center dba/Alluvion Health
______ Representative: City Law Enforcement
______ Representative: Sheriff’s Office
List special experience or education you may have for serving on this council.
(Include additional information on the back of this form or attached a resume.)
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CASCADE COUNTY Mental Health Local Advisory Council Application (Cascade County)

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Completed 17 July 2020

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