2009 Preliminary Board Membership Application Form by xit6H7

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									                                               Tri-County Board
                                               of Recovery & Mental Health Services

         1100 W ayne Street • Suite 4000 • Troy, OH 45373 • (937) 335 -7727 • 1-800 589-2853 • FA X (937) 335 -8816




                    PRELIMINARY BOARD MEMBERSHIP APPLICATION

Please e-mail the completed form to browna@mdsadamhs.mh.state.oh.us or FAX the form to 335-8816.

Contact Information - Home
Name:
Address:
Phone:                                                        E-mail:
Mobile phone or daytime contact:

Contact Information - Work
Place of Employment/Title:
Address:
Phone:                                                        E-mail:

County of Residence
            Darke                                Miami                                    Shelby

Type of Application/Appointing Authority
            ODMH                                 ODADAS                                   Commissioner
*Application descriptions are found on pg. 2. A full application will need to be completed once the
appointing authority is determined.


How did you learn of openings on the Tri-County Board?

What is your experience and/or interest in mental health and addictions issues? (professional, advocate,
family member, consumer, etc.)




Please indicate any skills and/or expertise you would bring to the Board of Directors that would enhance
the tri-county mental health and recovery system. (financial, clinical, advocacy, public relations, etc.)




Signature                                                                          Date


2009 Preliminary Board Member Application                                                                             Page 1
                                               Tri-County Board
                                               of Recovery & Mental Health Services

         1100 W ayne Street • Suite 4000 • Troy, OH 45373 • (937) 335 -7727 • 1-800 589-2853 • FA X (937) 335 -8816



                                           Board Member Appointments

The Tri-County Board of Recovery & Mental Health Services is an 18-member board mandated by ORC
chapter 340 to plan, fund, monitor and evaluate mental health and alcohol or drug addiction services for
Darke, Miami and Shelby counties. Membership includes consumers of mental health or alcohol or drug
addiction services, family members of such persons, physicians, professionals in the field of alcohol or
drug addiction services, mental health professionals, and other members of the community interested in
mental health and substance abuse issues. All members are residents of Darke, Miami or Shelby County.

Members are appointed by each set of County Commissioners, the Ohio Department of Mental Health
and the Ohio Department of Alcohol & Drug Addiction Services. Each member shall be appointed to the
Board for a term of 4 years. No members shall serve more than two consecutive four-year terms. A
member may serve for three consecutive terms only if the first term was a partial term and was less
than two years.

The following are guidelines for Board Membership appointment:

ODMH

The Director of the Ohio Department of Mental Health appoints four members to the Board of
Directors; a mental health professional, a Psychiatrist or MD, a person who has received or is receiving
mental health services, and a family member of such a person.

ODADAS

The Director of the Ohio Department of Alcohol and Drug Addiction Services appoints four members to
the Board of Directors; a professional in the field of alcohol or drug addiction services, an advocate for
persons receiving treatment for alcohol or drug addiction, a person who has received or is receiving
services for alcohol or drug addiction, and a family member of such a person.

Commissioner

The County Commissioners appoint 10 members to the Board of Directors who have a strong interest in
community service on a volunteer Board and sensitivity to mental health and substance abuse issues.




 The Tri-County Board is an Equal Opportunity Employer. Minority candidates are encouraged to apply.




2009 Preliminary Board Member Application                                                                             Page 2

								
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