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System Membership Application

Step 1 of 3 - Contact Information

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Contact Information
System Name*
Address*
City State ZIP Code
Phone*
Fax
Website
Email*
Tax Status*
Contact Name*
First Last
Please mail your membership-dues check to:
National Association for Behavioral Healthcare
900 17th Street, NW, Suite 420
Washington, DC 20006

(To determine your dues, you must complete the net revenue section of this application.)
Contact Phone/Extension*
Is your system part of a larger entity?*

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System Information
Please review the descriptions below and choose only one option that best describes your system.*
- Multi-facility Organization: An organization that owns, operates or manages two or more facilities/ programs/centers
- Specialty Inpatient Hospital: An organization licensed by the state and operated as a hospital primarily concerned with the provision of inpatient care to persons with mental illness or addiction
- General Hospital Psychiatric Unit: A unit in a general hospital or a facility licensed as part of a general hospital that is solely dedicated to the delivery of mental health and/or substance use disorders
- Residential Treatment Center—Mental Health: An organization licensed to provide overnight mental healthcare in conjunction with an intensive treatment program in a setting other than a hospital
- Residential Treatment Center—Substance Use: An organization licensed to provide overnight substance use care in conjunction with an intensive treatment program in a setting other than a hospital
- Partial Hospitalization Program: A planned program of mental health or substance use treatment services provided to groups of patients with three or more sessions per day
- Intensive Outpatient Program: A prescribed course of mental health or substance use disorder treatment in which the patient receives outpatient care no fewer than three times a week (this may include more than one service per day)
- Outpatient Center: An organization providing services outside a hospital setting
- Opioid Treatment Program: An accredited treatment program with Substance Abuse and Mental Health Services Administration (SAMHSA) certification and Drug Enforcement Administration (DEA) registration to administer and dispense opioid agonist medications that are approved by the Food and Drug Administration (FDA) to treat opioid addiction
- Therapeutic School: Day programs or 24-hour settings that provide an integrated environment focused on the physical, emotional, behavioral and academic development for youth
- Community Mental Health Center: A community mental health facility that provides behavioral health services; depending on the facility, these services may include inpatient and outpatient treatment, emergency care, individual and family therapy, support groups, health education, screenings, and psychosocial rehabilitation
Describe levels of care provided and populations served:*
- Inpatient (hospital)
- Residential
- Partial hospitalization
- Outpatient
(check all that apply)
Inpatient (hospital)
- Children
- Adolescents
- Adults
- Older adults
Residential
- Children
- Adolescents
- Adults
- Older adults
Partial hospitalization
- Children
- Adolescents
- Adults
- Older adults
Outpatient
- Children
- Adolescents
- Adults
- Older adults
Dues are based on the net revenue for all behavioral healthcare components of your system.

All information provided will be kept confidential.

Net Revenue: Gross behavioral healthcare patient care revenue minus contractual allowances, bad debt, charity care, research grants, and endowment revenue.
Timeframe for reporting revenue is the most recent fiscal year. Reporting period is:*
System Net Revenue:*
You pay: $3,500
You pay: $4,500
You pay: $6,500
You pay: $7,500
You pay: $8,500
You pay: $10,500
You pay: $17,000
You pay: $30,000
You pay: $65,000
You pay: $100,000
You pay: $170,000
You pay: $220,000
You pay: $270,000
You pay: $320,000
You pay: $370,000
You pay: $400,000
You pay: $450,000
You pay: $450,000 + $50,000 per $200 million above $1.3 billion
Please fill in total Net Revenue if it is higher than $1.3 billion:

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Personnel
Employee 1
Position
Name
First Last
Employee 2
Position
Name
First Last
Email
Employee 3
Position
Name
First Last
Email
Employee 4
Position
Name
First Last
Email
Please provide a list of all the facilities you operate.

This list will be used to share our weekly newsletter with the CEOs of all your facilities.
Number of Facilities
Facility 1
Facility 1 Name
Facility 1 Address
Street Address Address Line 2 City State ZIP Code
Facility 1 Website
Facility 1 Email
Facility 1 Chief Exectuvie Officer
Prefix First Last Suffix
Facility 1 Chief Executive Officer Email
Facility 2
Facility 2 Name
Facility 2 Address
Street Address Address Line 2 City State ZIP Code
Facility 2 Website
Facility 2 Email
Facility 2 Chief Exectuvie Officer
Prefix First Last Suffix
Facility 2 Chief Executive Officer Email
Facility 3
Facility 3 Name
Facility 3 Address
Street Address Address Line 2 City State ZIP Code
Facility 3 Website
Facility 3 Email
Facility 3 Chief Exectuvie Officer
Prefix First Last Suffix
Facility 3 Chief Executive Officer Email
Facility 4
Facility 4 Name
Facility 4 Address
Street Address Address Line 2 City State ZIP Code
Facility 4 Website
Facility 4 Email
Facility 4 Chief Exectuvie Officer
Prefix First Last Suffix
Facility 4 Chief Executive Officer Email
Submitted By
Name*
First Last
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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