COMMUNITY AWARD NOMINATION FORM

31stANNUAL BEHAVIORAL HEALTH RECOGNITION DINNER

NOTE: Community Award nominees in the first box may be individuals from adult, older adult, transitional age youth or children’s behavioral health services, and clients or family members. Community Award nominees in the second box may be individuals, programs or facilities.

Name of NomineeTelephone

Address

Please type or PRINT your answers to all the questions on the back of this form. Feel free to use 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.

COMMUNITY AWARD CATEGORIES (Check ONLY one for your nominee)

Community Awards for Individuals Only
1. Administrative Support Staff (clerical, medical records, technical or information services support)
2. Case Manager (person acting in a case manager role regardless of title)
3. Clinician (physician, social worker, psychologist, therapist, nurse)
4. First Responder (law enforcement personnel, fire fighters, paramedics)
5. Manager (program manager or director, program or service administrator not involved in direct care)
6. Outpatient Services (staff member providing direct care, for example, clinics, day treatment, partial hospitalization, intensive outpatient programs)
7. Self-Help (clubhouse staff, consumers or advocates for self-help programs)
8. Service Support (home aides, housekeepers, maintenance workers, transportation, security staff)
9. Volunteer serving in a behavioral health program
These three Community Award categories are for either individuals, programs or facilities
10. Housing (staff member, program or facility, such as supportive housing, independent living, residential care facilities, group or foster homes, transitional housing, housing coalitions)
11. Vocational or Educational Support (staff member, program, or facility including peer and family educators, job coaches, etc.)
12. 24-Hour Treatment Facility (staff member, program or facility providing direct care to children, transitional age youth, adults, or older adults in a 24-hour treatment facility)
  1. Who is your nominee (a nominee may be a person, or, for categories 10 – 12 only, also a program or facility)? What is your nominee’s role in the behavioral health community?
  1. Tell us how your nominee demonstrates outstanding performance and willingness to go beyond the requirements of that role.
  1. Tell us how your nominee demonstrates the ability to work with children, transitional age youth, adults, older adults or family member(s) and to advocate for their rights.
  1. Tell us how your nominee works to ease stigma.
  1. Tell us how your nominee promotes culturally competent behavioral health services for everyone, regardless of level of functioning, age, gender, sexual orientation, culture, language, etc.
  1. Please attach a summary, in 150 words or less, why you believe this person (or program or facility for categories 10 – 12) should receive 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)

E-mail 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 619-232-9663.

E-Mail completed form to:

Or mail completed form to:Community Awards

Behavioral Health Recognition Dinner

P. O. Box 84243

San Diego, CA 92138-4243

2/22/17 Community Awards