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Application For Advisory Committee Membership - Texas Health And Human Services Commission Page 2

Please indicate where you would like to receive further communications:

Work Email

Home Email

Work Address

Home Address

Application

New/Initial Application

Renewal Application

Gender

Male

Female

Race/Ethnicity

American Indian/Alaskan Native

Asian/Pacific Islander

Black

Hispanic

White

Other

SECTION 2 (Recipients/Family Applicants Only)

An individual with behavioral health conditions who are current or former recipients of

publicly funded behavioral health services may apply to be on this committee. We call this

individual a "recipient." A family member of a current or former recipient may apply to

be on this committee. A "family member" may be the parent, spouse, guardian,

grandparent, or adult sibling of the current or former recipient.

Please complete SECTION 2 only if you are a recipient or a family member.

Please tell us about your direct experience with the Texas publicly funded behavioral

health system.

Please tell us why you want to serve on this committee.

SECTION 3 (Professional Applicants Only)

A professional may apply to be on this committee. Professional applicants include:

providers; professional associations; non-profit organizations; managed care organizations

and other subject matter experts.

Please complete SECTION 3 only if you are a professional applicant. Attach a resumé

and/or certification.

Describe your direct knowledge of the publicly funded behavioral health system in Texas.

HHSC is an equal opportunity employer and provider.

Application For Advisory Committee Membership - Texas Health And Human Services Commission Page 2