Respite Partnership Collaborative Member Application Form
Member Application Form - two pages
Please submit your completed Member Application Form (two pages),
including responses to the Applicant Questions (three pages maximum)
Refer to the Member Application Instructions for
RPC background and submission instructions
APPLICANT’S NAME:
PHONE NUMBER:
CELL
HOME
ADDRESS:
ORGANIZATION (if applicable):
E-MAIL ADDRESS:
WORK
CITY:
ZIP CODE:
APPLICANT DEMOGRAPHICS (Check all that apply)
Male
Age:
Female
16-17
18-24
Ethnicity
AfricanAsianand
American/Black American/API
Race:
Culture:
Self Identification:
Transgender
25-59
60+
Latino/a
Caucasian
Primary Language:
Native
American
Other:
_________
Self Identification (for example: Arab American; Lesbian, Gay, Bisexual, Transgender, Questioning
(LGBTQ); Slavic)
LIVED MENTAL HEALTH EXPERIENCE (Check all that apply)
Adult Consumer of Mental Health Services
Older Adult Consumer of Mental Health Services
Family Member of an Adult Consumer of Mental
Health Services
Parent/Caregiver of a Child with Complex Mental
Health Needs
Adult Consumer of Mental Health Services with
Dependent Children in the Household
Teen/Transition Age Youth (16-24) Consumer of
Mental Health Services
Family Member of an Older Adult Consumer of
Mental Health Services
Not Applicable
2014 Respite Partnership Collaborative Member Application Form and Questions
Updated March 2015
www.shfcenter.org/rpc
1
Respite Partnership Collaborative Member Application Form
Member Application Form- two pages
E-mail applications to rpc@sierrahealth.org
APPLICANT STAKEHOLDER REPRESENTATION (Check up to three that apply)
Each Respite Partnership Collaborative member is requested to represent a community stakeholder perspective.
RPC members are to bring forth their stakeholder perspective to inform the collaborative process around mental
health respite. Please review the list below and identify up to three stakeholder groups you are able to
represent to bring forth those viewpoints to the RPC collaborative process if selected as a member.
Individual with Lived Mental
Alcohol and Other Drug Service
Aging and/or Older Service
Health Experience or Family
Provider
Provider
Member (in reference to the
experiences listed in the box on page
1)
Child Welfare and/or Foster
Care
Education
Health Sector
Hospital Council/Community
Mental Health Partnership
Law Enforcement
Please specify:
Nontraditional Mental
Health Provider inclusive of peerrun services, spiritual healing and
alternative medicine. Please
specify:
Transition-Age Youth
Cultural or Ethnic Community
Please specify:
Faith-Based Organization
Homeless, Lived Experience
Hospital Emergency Department
Representation. Please specify:
Mental Health Service Provider
Association
Children
Adults
Patient Rights Advocate
Veterans
Disability Organization
Foster Youth
Homeless Service Organization
Juvenile Justice
Organization Serving Children
and Youth
Please specify:
Persons with Disability
Other:
PRIMARY STAKEHOLDER GROUP IDENTIFICATION (Identify one primary stakeholder from the list above)
1.
Based on the stakeholder groups you identified above, please use this space to identify the primary
stakeholder group you would represent on the Respite Partnership Collaborative:
2. Please provide a brief description of your link to the primary stakeholder group you would represent on the
Respite Partnership Collaborative:
MEETING WITH RPC REPRESENTATIVES
WHAT DATE DO YOU ANTICIPATE ATTENDING AN RPC MEETING AND/OR MEET WITH RPC REPRESENTATIVES?
Please refer to the Application Instructions for a list of upcoming RPC meeting dates.
2014 Respite Partnership Collaborative Member Application Form and Questions
Updated March 2015
www.shfcenter.org/rpc
2
Respite Partnership Collaborative
Member Application Questions - three pages maximum
Please submit your completed Member Application form (two pages), including responses to the
following Applicant Questions (three pages maximum) to rpc@sierrahealth.org. Please provide detailed
answers to the questions below to inform the reviewers of your background and experience with
collaboration and mental health crisis.
Refer to the Member Application Instructions for
RPC background and submission instructions
1. Please describe why you are interested in serving on the Respite Partnership Collaborative (RPC).
Describe how you will maintain an active 80 percent attendance commitment level for your RPC
membership term.
2. What steps will you take to stay in communication with your identified primary stakeholder group to
articulate their needs for mental health respite to the RPC? How will you as an RPC member keep
this stakeholder group informed on the progress of the RPC?
3. What similar process have you participated in that involved diverse stakeholders coming together to
support a common goal? Please describe how you participated within the group to support it in
reaching its goal.
4. Do you have any experience dealing with hospitals, treatment centers, and/or emergency rooms
during a mental health crisis? If so, what from your experience could you share to help inform the
RPC?
5. What skill set or experience would you bring to the RPC? How would you use your skill set to
support the RPC in evaluation activities, developing communication strategies and/or work toward
sustainability?
6. Please provide any additional information about your experiences or background you feel is relevant
to mental health and/or mental health respite needs in Sacramento County.
2014 Respite Partnership Collaborative Member Application Form and Questions
Updated March 2015
www.shfcenter.org/rpc
3