BEHAVIORAL HEALTH PERSON OF THE YEAR

REVISEDNOMINATION FORM - DUE DATE EXTENDED

32ndANNUAL BEHAVIORAL HEALTH RECOGNITION DINNER

Behavioral Health Person of the Year nominees may represent adult, older adult, transitional age youth or children’s behavioral health services, and the clients, families, or the community at large. They may be nominated for their collective body of work.

Name of Nominee

Nominee’s Mailing Address

Nominee’s Telephone Number: HomeWork

Nominee’s Email Address

Please type or PRINT all of your answers. Questions continue on the second page of this form. Feel free to answer the questions on a separate piece of paper, or to answer directly on this Word document, expanding form as needed. If you need assistance completing your nomination, don’t hesitate to ask someone you rely on to help you. You may include up to3 supporting letters if you wish. Please include the mailing address of the person(s) writing the supporting letters.

  1. What is your nominee’s role in the behavioral health community? How long has your nominee been involved in the community?
  1. Focusing on leadership and providing specific examples, describe the extra efforts your nominee makes or has made to benefit others in the behavioral health community in ways truly “above and beyond the call of duty.” What innovative approaches supporting behavioral health has your nominee championed? How has he or she, through that leadership, helped shape the behavioral health community?
  1. Give specific examples ofwhat your nominee does or has done to ease stigma,ensure clients and/or family members have a voice in decision making, and make culturally competent services available to everyone, regardless of functioning, age, gender, sexual orientation, culture, language, etc.?
  1. Providing specific examples, tell us what your nominee does or has done to help clients improve their ability to function independently in the community, i.e., increasing social skills, increasing vocational skills, increasing self-management of behavioral health, etc.
  1. Using specific examples, tell us what your nominee does or has done to advocate for the rights of children, transitional age youth, adults, older adults and family member(s), locally, statewide and/or nationally.
  1. Using 150 words or less, please provide a summary telling us why your nominee deserves this award. (This summary will not be rated by the judges.)

Name of person completing this form (PRINT) (required)

Signature of person completing this form (required)

Telephone Number: (required) HomeWork/Cell

Email address of person completing this form (optional)

If you have questions about this form, call Gale Osborn at 619-543-0918 or Marianne Wedemeyer at 619-584-5023.

Email completed form to:

OR mail completed form to:Behavioral Health Person of the Year Award

Behavioral Health Recognition Dinner

P. O. Box 84243

San Diego, CA 92138-4243

*NOTE: Only USPS postmarks will be recognized as proof of timely submission – not private postage meter marks.

SEE A LIST OF ALL WINNING NOMINATIONS BY MID MAY AT BHRDSANDIEGO.NET

3/20/18 Behavioral Health Person of the Year