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Advocacy Information Form

Name:

 

Email Address:

 

Home Address:

 (Home address is needed to connect you with your elected leaders)

 

City:

 

State:

 

Zip:

 

Home Phone:

 

Business Phone:
Fax:

 

Organization:

 

Position or Title:

 

Business Address:

 

City (business) :

 

State: (business)

 

Zip:
What is your preferred mailing address?     Home    Business  
Please answer a few short questions

1. Please let us know of any special areas of behavioral health that interest or affect you:

(e.g., adult or children's  behavioral health, substance abuse/dependency, family support...)

 

2. For accepting our invitation to join our advocacy efforts, we will send you our quarterly newsletter, "Changing Minds" How would you like to receive your copy?   

Email:     Hard Copy 

 

3. Are you affiliated with, or do you volunteer for any community organizations?

 
 
 

 

If you questions, comments or concerns, please email us  or call us @ (401) 228-7990    

©2003 Rhode Island Council of Community Mental Health Organizations, Inc