Last Name

First Name

Phone

ID County

Do you identify as a person currently receiving mental health or substance use services? YesNo

Do you identify as the parent or caregiver of a child or youth, under the age of 18, who is currently receiving mental health or substance use services? YesNo

Do you identify as the parent or caregiver of an adult, 18 years of age or older, who is currently receiving mental health or substance use services? YesNo

Can you commit to attending virtual committee meetings on the third Thursday of each month at 1:00 p.m. MT/12:00 p.m. PT for one year (12 months)? YesNo

Why are you interested in joining the MFAC?

Please tell us what strengths you would bring to the MFAC?

Previous experience in advisory committees or advocacy work is not required. However, if you have prior experience in advisory and advocacy activities, please share:

Do you have any questions for the MFAC organizers about the application process?

I understand that my participation in Magellan’s MFAC is to represent my lived experience with Idaho’s mental health and substance use services and not to represent an agency or organization. YesNo

How did you hear about Magellan Healthcare?

Would you like to receive information and updates from Magellan Healthcare? If so, please select an option: Member communicationsGovernment/community organization communications

Are you over the age of 18? YesNo

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