QuIC's Central Coordinating Council Online Application

To apply for membership in the Central Coordinating Council (CCC) of Connecticut's Consumer, Youth, and Family Quality Improvement Collaborative (QuIC), please complete and submit the application below.

Please make sure you have reviewed the Member Information and Expectations before submitting your application (MS Word document - opens in a new browser window).

– QuIC –
Central Coordinating Council Member Application

Your name:
Mailing address:
City:
State:
ZIP Code:
Home phone:
Work phone:	Ext.
Cell phone:
Fax:
Email:
Please retype email:
Best day and time to call to schedule an interview:
Please Tell Us About Yourself…
Your date of birth:    (mm/dd/yyyy)
Which phrase(s) best describe you? (Check all that apply)     Consumer/Person in Recovery who has received or is receiving mental health services     Family Member of a Consumer/Person in Recovery who has received or is receiving mental health services - If family member, the consumer is your:   (e.g., son, mother, etc.) …and his or her age is:
Your race and ethnicity:  White/Caucasian  African-American  Latino/Hispanic  Asian  American Indian  Other …If other, please tell us:
I am involved with the following agencies, organizations, committees, or groups:
What services have you received or are familiar with? (e.g. DMHAS, DCF, other agencies, etc.)
Please tell us what skills, academic training, or other experiences and interests you could bring to the CCC:
Why do you want to become a member of the Central Coordinating Council:
If you are a consumer youth or young adult family member, what is the most important change you would like to see?
Please tell us what day(s) and time(s) you are available to regularly come to a two-hour monthly meeting (check all that apply): Mon.Tues.Wed.Thurs.Fri. Morning (9:00am - Noon) Afternoon (Noon - 4:30pm) Early Evening (4:30 - 6:30pm)
Please verify and agree… By checking these boxes, you are indicating that you verify and agree to the following statements:
Yes, I have read and understand the Member Expectations
I understand that submitting this application and having an interview does not guarantee that I will be selected as a member of the CCC