MHA-Kentucky Award Application
The Frank M. Gaines, MD, Award is given in memory of a Louisville psychiatrist instrumental in the work of several nonprofit mental health agencies, including MHA Kentucky, to recognize the significant contributions of an active or retired professional to the care and treatment of people with mental illnesses.

The Jack B. Stith Award recognizes an individual with an outstanding record of volunteer advocacy for persons with serious mental illnesses.

The Philip P. Ardery Award honors a program or organization that provides a significant service to the local or statewide community regarding the promotion of mental health or the prevention of mental illness.

The Clifford W. Beers Award honors a consumer of mental health services who emulates the work of Clifford W. Beers, a consumer who founded Mental Health America, to improve conditions for and attitudes toward people with mental illnesses.

Nominee Name *
Your answer
Nominee Phone # *
Your answer
Nominee Email Address *
Your answer
Nominee Title/Role
Your answer
Which Award are you nominating this person for? *
Brief Biological Sketch of the nominee, including education and professional credentials *
Your answer
Brief Synopsis of Prior and Current Activities that Qualify Nominee for this award: *
Your answer
Any other information we should have? *
Your answer
Name of Person Nominating *
Your answer
Phone # of Person Nominating *
Your answer
Email of Person Nominating *
Your answer
Relationship to the Nominee: *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service