APPLICATION FORM FOR DISABILITY RIGHTS TEXAS PAIMI ADVISORY COUNCIL If you would like to be considered for the Disability Rights Texas PAIMI (Protection and Advocacy for Individuals with Mental Illness) Advisory Council, please complete the application and submit it any time during the year along with a copy of your resume. Date: ___________________________ Name: _____________________________________________________________ Address: ___________________________________________________________ City: ___________________________ State: _________ Zip Code: ___________ E-mail: ____________________________________________________________ Phone: ___________________________ Occupation: _______________________ Employer: _________________________________________________________ Please answer all of the following questions. You may attach additional pages if you need more room to answer. What is your interest and motivation for serving as a PAIMI Advisory Council member?

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Please explain your knowledge of the issues affecting persons with mental health issues.

Describe your experience in community organizations, including service on boards or advisory committees.

Describe your experience with and/or knowledge from working with specific underserved communities (e.g., Asian/Pacific Islander, African American, Native American; Hispanic and/or Spanish-speaking, blind, deaf/HH, homeless, veterans or any fore mentioned in rural communities).

Describe your experience advocating for people with disabilities or others.

Describe your leadership or policy development experience.

Are you a member of other disability or civil rights organizations? If so, please identify those groups below.

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I live in the area (region) identified below: *If you are unsure, please reference “Counties by Region” chart on last page of application. Central Texas North Texas South Texas East Texas West Texas El Paso DRTx’s PAIMI Advisory Council values diversity. In order to assist the Council in selecting diverse Council members, please identify the answers below that best describe you: Age Group: 18-25 26-39 40-64 65+ Ethnicity: African American Asian/Pacific Islander Native Hawaiian or other Pacific Islander Hispanic/Latino Alaskan Native Native American White Multi-racial Decline to state Other: _________________________________________

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Category under which you qualify for the PAIMI Advisory Council: Parent of a minor child (under 18 years of age) who is receiving or has received public mental health services Attorney Mental Health professional (i.e., psychiatrist, clinical psychologist, clinical social worker, psychiatric nurse, mental health counselor, professional counselor and/or other position where you have received a bachelor or advanced degree to provide mental health professional services) Individual from the public who is knowledgeable about mental illness Mental Health service provider (i.e., peer advocate, support liaison and/or other position where you received training to provide mental health services) Individual who has received, or is receiving, mental health services Family member of an individual who has received, or is receiving, mental health services Please indicate if you are an individual who has received or is receiving mental health services or if you are a family member of an individual who has received or is receiving mental health services? Yes No Your signature (below) is requested as an indication of your commitment to the purpose and responsibilities of the PAIMI Advisory Council. __________________________________ (Signature)

_______________________ Date:

Fragrance Free Policy: In order to accommodate persons with Multiple Chemical Sensitivity, asthma, or other similar conditions, persons attending the DRTx PAIMI Advisory Council meetings are requested to refrain from using perfume, cologne and other fragrances for the comfort of other Council members and other participants.

Please forward your application to: Sara Record Disability Rights Texas 2222 W. Braker Lane Austin, Texas 78758 If you have questions or need assistance completing the application, call Sara Record at (512) 454-4816. You may also e-mail your application to [email protected].

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