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Alameda County Care Connect Consumer and Family Fellowship Nomination Form

We are now accepting applications.

We are seeking nominations from health care providers, community-based and family/consumer organizations. If you are a direct consumer of county care and services or a family member of someone who is, you may also apply. Please apply below.

1. Please select whether you are applying or nominating someone else. *This question is required.

2. Your Name *This question is required.

2. Your Address *This question is required.

2. Your Phone Number *This question is required.

2. Alternate Phone Number

2. Your email address *This question is required.

2. Name of Candidate *This question is required.

2. Candidate Address *This question is required.

2. Candidate Phone Number *This question is required.

2. Alternate Phone Number

2. Candidate email *This question is required.

2. Your Name (Nominating Service Provider) *This question is required.

2. Title *This question is required.

2. What agency or organization do you work for/represent? *This question is required.

2. Contact Phone *This question is required.

2. Contact Email *This question is required. This question requires a valid email address.

2. 1. Is the candidate a: *This question is required.

Space Cell	Yes	No
Consumer	Consumer: Yes	Consumer: No
Family Member of a Consumer on Medi-Cal	Family Member of a Consumer on Medi-Cal: Yes	Family Member of a Consumer on Medi-Cal: No

2. 1. Are you a: *This question is required.

Space Cell	Yes	No
Consumer	Consumer: Yes	Consumer: No
Family Member of a Consumer on Medi-Cal	Family Member of a Consumer on Medi-Cal: Yes	Family Member of a Consumer on Medi-Cal: No

2. 2. Tell us about why you think this person would be a strong candidate for the Consumer and Family Fellowship and how you have partnered with this consumer or family member? *This question is required.

2. 2. Tell us why you are a strong candidate for the Consumer and Family Fellowship? *This question is required.

2. 3. Does this candidate require any special accommodations? *This question is required.

2. 3. Do you require any special accommodations? *This question is required.

2. 3a. If yes, please explain:

2. 4. What systems/organizations does the candidate have lived experience with (as a consumer or supporting a loved one): *This question is required.

Healthcare/Public Health System
Mental Health/Behavioral Health System
Housing/Homeless
Criminal Justice Agencies
Community Based Organizations
Consumer Organization
Family Organization

2. 4. What systems/organizations do you have lived experience with (as a consumer or supporting a loved one): *This question is required.

Healthcare/Public Health System
Mental Health/Behavioral Health System
Housing/Homeless
Criminal Justice Agencies
Community Based Organizations
Consumer Organization
Family Organization

2. 5. Does the candidate meet the following requirements: *This question is required.

Space Cell	Yes	No
Live in Alameda County	Live in Alameda County: Yes	Live in Alameda County: No
Currently on Medi-Cal (Consumers only)	Currently on Medi-Cal (Consumers only): Yes	Currently on Medi-Cal (Consumers only): No
Able to attend professional development activities	Able to attend professional development activities: Yes	Able to attend professional development activities: No
Able to commit 10-12 hours per month from July 1, 2018 - June 30, 2019	Able to commit 10-12 hours per month from July 1, 2018 - June 30, 2019: Yes	Able to commit 10-12 hours per month from July 1, 2018 - June 30, 2019: No

2. 5. Do you meet the following requirements: *This question is required.

Space Cell	Yes	No
Live in Alameda County	Live in Alameda County: Yes	Live in Alameda County: No
Currently on Medi-Cal (Consumers only)	Currently on Medi-Cal (Consumers only): Yes	Currently on Medi-Cal (Consumers only): No
Able to attend professional development activities	Able to attend professional development activities: Yes	Able to attend professional development activities: No
Able to commit 10-12 hours per month from July 1, 2018 - June 30, 2019	Able to commit 10-12 hours per month from July 1, 2018 - June 30, 2019: Yes	Able to commit 10-12 hours per month from July 1, 2018 - June 30, 2019: No

2. 6. Does this person have any experience serving on and advisory, steering, oversight, governing board? *This question is required.

2. 6. Do you have any experience serving on and advisory, steering, oversight, governing board? *This question is required.

2. 6a. If yes, describe:

2. 7. Have you had a chance to talk to the candidate about the nomination and its requirements? *This question is required.

Please provide us with 2-3 personal references

Please provide 1-2 additional references for the candidate

2. Reference 1 *This question is required.

Name
Contact Number
Alternate Number
Relationship to Candidate

2. Reference 2

Name
Contact Number
Alternate Number
Relationship to Candidate

2. Reference 3

Name
Contact Number
Alternate Number
Relationship to Candidate