CMHA Champlain East

Name

Mailing Address (Incl. Postal Code)

Telephone

Email

Which community do you live in?

Stormont Dundas Glengarry Prescott

Which of the following age categories do you fall into?

What is your preferred language? What languages do you speak? Please check all that apply.

English French Other

If you do not feel comfortable communicating in either of these, what is your language of communication?

Which of the following best describes you? Please check all that apply.

as a client as a family member/friend of client as a caregiver as both a client and family member/caregiver

Which CMHA Champlain East programs or services do you, your family, or the person you care for have experience with? Please check all that apply.

Intensive Case Management Services

Intensive Case Management Supportive Housing Program Hoarding Program Family Support Youth in Transition Court Diversion/Pre-charge Diversion Program Court Support Support Employment/Vocational

Peer Resource Centers

Social Recreation Activities Focus on Fitness Support Groups Youth Groups

Groups

Whithout sharing any personal health information, briefly describe your experience with CMHA Champlain East and the mental health and/or addictions health services and wha unique perspective you would bring to the CMHA Champlain East Client & Cargiver Advisor Council (CFCAC).

Please indicate level of commitment in the following areas:

I am passionate about enhancing the client experience

Yes No

I amin a healthy place in my own recovery and can actively contribute

Yes No

I am open-minded and have a positive attitude

Yes No

I am comfortable speaking in front of others

Yes No

I am comfortable speaking in front of others about the mental health and/or addictions services, programs and/or care I accessed as part of my own

Yes No

Please indicate your experience in the following areas. If "Yes" please provide a brief description of your background and experience

Sitting on a formal or informal advisory council or committee

Yes No

Descrption

Leading a group or committee (e.g. parent-teacher association).

Yes No

Descrption

Specialized areas of expertise (e.g. process improvement, quality, education, strategic planning, communications, marketing)

Yes No

Descrption

Working within the health care sector (e.g., mental health, addications, childresn & youth, seniors, complex care, long-term care, or work within a community agency.

Yes No

Descrption

Please let us know if your require any specific accommodation needs in order to participate on the committee. If you prefer to discuss this with someone, we can contact your directly - please let us know below when is best to reach you?

Which of the following times are you available to attend in-person quarterly meetings?

Check all that Apply.

Weekday Mornings (e.g. 9am-11am) Weekday Mid Days (e.g. 11am-1pm Weekday Early Afternoons (e.g.1pm-4pm) Weekday Later Afternoons (e.g.4pm-6pm) Weekday Evenings (e.g. 7pm-pm)

Please let us know if you have access to the following.

Cell and/or home phone Internet Access Personal E-Mail

Please check to indicate that you are willing to actively participate in on going CFCAC initiatives for the next 2-year term.

Please check to indicate that you are agreeing to the CMHA Volunteer policy which requires all active volunteers to submit a police record and vulnerable sector screening.

In addition to completing the above, you may also wish to attach a current copy of your resume (if applicable) and cover letter for consideration.

Only following file types are accepted: jpg,png,jpeg,bmp,gif,doc,pdf,JPG,PNG,JPEG,BMP,GIF,DOC,PDF

Maximum upload size: 64.00 MB

CFCAC Application Form

Which CMHA Champlain East programs or services do you, your family, or the person you care for have experience with? Please check all that apply.

Please indicate level of commitment in the following areas:

Please indicate your experience in the following areas. If "Yes" please provide a brief description of your background and experience

Which of the following times are you available to attend in-person quarterly meetings?

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