BEHAVIORAL HEALTH PERSON OF THE YEAR

NOMINATION FORM

31stANNUAL 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 Telephone Number: HomeWork

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. Who is your nominee? Describe your nominee’s role in the behavioral health community. How long has your nominee been active in the community? Tell us what makes his or her contribution to the community truly “above and beyond the call of duty.” What innovative approaches to the support of behavioral health has your nominee championed? How has his or her leadership helped shape the behavioral health community?
  1. Tell us how your nominee works with the client or family member and includes them in decision-making.
  1. Tell us how your nominee works toward easingstigma.
  1. Tell us how your nominee supports clients’ efforts to improve their functioning in the community, i.e., increasing social or vocational skills.
  1. Tell us how your nominee responds to the needs of special populations, such as children, transitional age youth, seniors, persons with dual or multiple diagnoses, or persons with physical disabilities.
  1. Tell us how your nominee promotes culturally competent behavioral health services for everyone, regardless of functioning, age, gender, sexual orientation, culture, language, etc.
  1. Please attach a summary, in 150 words or less, why you believe this person 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) HomeWork/Cell

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:Behavioral Health Person of the Year Award

Behavioral Health Recognition Dinner

P. O. Box 84243

San Diego, CA 92138-4243

2/22/17 Behavioral Health Person of the Year