MaMHCA Awards Nomination Form

Your First Name *

Your Last Name *

Please Indicate Your Membership Category *

MaMHCA Member

Non-MaMHCA Member

Name of Nominee *

Nominee Current Position or Title *

Please Indicate the Nominee's Membership Category *

MaMHCA Member

Non-MaMHCA Member

Please Check The Award Category You Are Nominating This Individual For (descriptions available here: https://www.mamhca.org/lmhcs/awards-program/) *

Mental Health Counselor of the Year

Counselor Educator of the Year

Professional Service and Leadership

Mental Health Agency of the Year

Lifetime Achievement Award

Please Provide a Brief Description of Why You Think the Nominee Deserves This Award? *

0/300 words

Nominee Email Address *

Nominee Phone Number *

Your Email Address *

Your Phone Number *

*Please Note: You may be contacted by the MaMHCA Awards Committee or Staff for additional information or materials in support of your nomintation.*