Consumer Speaks Award Nomination Form 2013

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Mental Health America of Northern California Sacramento County, Department of Health and Human Services Division of Behavioral Health Services

Deadline to Submit Monday, May 13, 2013

The Mental Health America of Northern California is requesting nominations for Consumer Speaks 2013 Awards in the following categories:

Please submit only one Nomination Form Please Print Nominator’s Name: Nominator’s Signature (Required): 1. Consumer Provider: Awarded to a provider working as a service provider within the mental health system who has shown a caring and supportive nature to clients within the last year. Name

Agency

2. Non-Consumer Provider: Awarded to a mental health worker or clinician who is not identified as a consumer who has shown an above average empathy to the clients he/she serves within the mental health system. Name

Agency

3. Volunteer of the Year: Awarded to a person who has made a difference in our system by supporting the concept of recovery and working within the mental health system to assist clients in their daily lives. This person can be a consumer, family member or public interest member who devotes time and energy on a volunteer basis. Name

Contact Number

4. Consumer Leader of the Year: Awarded to a person who has shown a degree of leadership over the last year by assisting other consumers to strive for a better quality of life by not only assisting others, but also living a life that is an example of leadership to their fellow consumers. Name

Contact Number

Please return this Nomination Form no later than Monday, May 13, 2013 along with a nomination paragraph for each nomination. Please send this nomination form to Andrea Crook at (916) 875-1490 (fax) or send requested information to Hillerman-CrookA@SacCounty.net Questions? Contact Andrea Crook at: Hillerman-CrookA@SacCounty.net Consumer Speaks Conference 05-23-2013


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