Prospective Board Member Interest Form

Please click here if you would prefer to print, fill out, and mail or fax  the interest form.

APPOINTMENT INFORMATION Board members are appointed by the following: County Commissioners (appoint 10 Board members, general appointments), the Ohio Department of Mental Health (appoint 4: physician, someone in recovery from a mental illness, a family member of a person with mental illness and a mental health professional) and the Ohio Department of Alcohol and Drug Addiction Services (appoint 4: someone in recovery from chemical dependency, a family member of someone who is chemically dependent and an advocate for alcohol/drug services and a chemical dependency professional). Please check any of the appointments you would consider below.

Name:*
First Name:
Last Name:
Address:*
Street:
City:
State:
Zip:
Country:
Home Phone:
Work Phone:
Email:
County Commissioners


Ohio Mental Health and Addiction Services (OhioMHAS)





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