Advocacy Empowerment Interest Form
NAMI Multnomah’s Advocacy Empowerment Group works with the System of Care Collaborative bring together parents, youth, providers and administrators to problem-solve barriers in the systems of care. By participating, you are using your voice to help impact how the county serves families, youth and children with mental health challenges.

Are you...

• the parent/caregiver of a child or adolescent who is the recipient of high levels of mental health services through Multnomah County and/or Wraparound services, within the last 2 years;
• and/or your child members of Health Share; AND
• ready, willing and able to share some of your stories, barriers and experiences in order to advocate for and effect change?

JOIN US!

Please fill out this form, and we will get back to you shortly. We are so looking forward to working with you!

Questions? Contact Dana at dana.hafter-manza@multco.us.

Parent/Caregiver Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Care Coordinator (if applicable)
Your answer
Family Partner (if applicable)
Your answer
Referred by: *
The following applies to me and/or and my family (check any/all that apply): *
Required
WE WANT TO HEAR YOUR VOICE! Please briefly explain what interests you about participating in the mental health advocacy for youth and family. Questions? Let us know! *
Your answer
By writing my full name below, I am expressing interest in participating in the Multnomah County System of Care Collaborative. NAMI Multnomah is authorized to have a representative contact me to discuss further details. *
Your answer
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