MENTAL HEALTH WEEK 2010

STATE PLANNING COMMITTEE

CONSUMER, CARER and NGO REPRESENTATIVES

EXPRESSION OF INTEREST
It is essential that we have feedback from consumers, carers and non-government
organisations in the development of Mental Health Week activities. We recognise that
everybody has something to contribute and so encourage you to complete this form.

We will be appointing one representative in each of the following categories:

• Consumer
• Carer
• NGO North Queensland (from Torres Strait to Mackay, including west to Mt Isa)
• NGO Central Queensland (south from Mackay to Maryborough including west to
Longreach and Blackall)
• NGO South Queensland (Gympie to Gold Coast, including Brisbane, Darling Downs west
to Cunnamulla and Charleville).

Please note that you will not be required to travel for this role. All meetings are held by
teleconference, the cost of which is covered by Queensland Health.

Thank you for expressing an interest in becoming a consumer, carer or non-government

organisation representative with the Mental Health Week 2010 State Planning Committee.

Please submit your Expression of Interest by Friday 19 February 2010.

If you have any queries or would like further information please contact Sharon Broadley
on 3234 1049.

Please return to: Mental Health Week 2010 State Planning Committee
c/- Fay Dykes
Mental Health Directorate
Queensland Health
PO Box 2368
FORTITUDE VALLEY BC QLD 4006

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PERSONAL INFORMATION

Surname:______________________ First name: __________________________

Address: ___________________________________________________________________

Town / Suburb:__________________ State: __________ Postcode: _________________

Telephone Number: _____________________ Mobile Number: __________________

Fax Number: ____________________ Email Address: ______________________________

Date of Birth: / /

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EXPERIENCE / SKILLS / INTERESTS

Please complete the following questions to help us evaluate your application. If you
require additional space please attach further details.

Question 1
If you’ve had any personal or work experience on committees or working groups, for example
CAG, ARAMFI, other NGO’s or charity groups, student councils, P & C Committees, please
provide details as to which committees/groups. In addition please state what your role was and
what you achieved whilst on the committee/working group.

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Question 2
Please outline what formal representation or roles in committees you have undertaken.

Question 3

Have you had any involvement or experience with Mental Health Services or other self help
groups including committees and working groups?

ο Yes ο No

Question 4

The Mental Health Week 2010 State Planning Committee will require members to be effective
representatives, with the ability to clearly communicate and provide a representative view to the
committee. Please provide details of the skills and or abilities you have to offer in this role.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_________________________________________________________________________

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__________________________________________________________________________

Question 5

Would you be able to consult with members of your network to get feedback for the Mental
Health Week 2010 State Planning Committee meetings?

ο Yes ο No

Question 6

How would you consult with others to ensure you were being representative of the wider views?
Please identify and give a brief explanation of how you would consult with others.

ο Face to Face

ο Attendance at CAG, or other groups (Eg: ARAFMI, GROW, etc.)

ο Send regular information

ο Telephone

ο Other

Can you use a computer? ο Yes ο No

Do you have access to a computer? ο Yes ο No

Do you have access to email? ο Yes ο No

Do you identify as a: ο Aboriginal ο Torres Strait Islander ο Aboriginal & Torres Strait
Islander

CONFIDENTIALITY STATEMENT

I _________________________________ agree to abide by the confidentiality rules and regulations within my

duties as a consumer / carer/ NGO representative on the Mental Health Week 2010 State Planning Committee
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I understand that if I am unsure of what is required of me in relation to confidentiality within this role that I will
request clarification from the chairperson of the Mental Health Week 2010 State Planning Committee or the
Secretariat. I agree to be bound by the confidentiality agreements that govern this committee on which I am a
representative.

I acknowledge and agree to be bound under Part 7 Section 62A of the Health Services Act (1991) regarding
confidentiality by employees of District Health Services which states:

‘A designated person or former designated person must not disclose to any other person, whether directly or
indirectly, any information (confidential information) acquired because of being a designated person if a
person who is receiving or has received a public sector health service could be identified from that
information’.

_________________________

Signature

/ / 2010

If you have any queries or would like further information please contact Sharon Broadley on 3234 1049.
Please submit your Expression of Interest by Friday 19th February 2010.

Please return to: Mental Health Week 2010 State Planning Committee
c/- Fay Dykes
Mental Health Branch
Queensland Health
PO Box 2368
FORTITUDE VALLEY BC QLD 4006

OR

Email: mhmarketing@health.qld.gov.au

Fax: 07 3238 9126

OFFICE USE ONLY

Consumer / Carer/ NGO Representative Appointed Yes No

Date of Appointment ……………………………………………………………………….

Appointment Period ……………………………………………………………………….

Approval By ……………………………………………………………………………………….

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