System Membership Application [vc_row][vc_column][vc_column_text] System Membership Application Form Step 1 of 3 - Contact Information 33% Contact InformationSystem Name* Address* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxWebsite Email* Tax Status*Not-for-profitFor-profitContact 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?*YesNo System InformationPlease 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:*Select oneBelow $7 million$7 million–$9.9 million$10 million–$19.9 million$20 million–$29.9 million$30 million–$39.9 million$40 million–$49.9 million$50 million–$59.9 million$60 million–$99.9 million$100 million–$150 million$151 million–$200 million$201 million–$300 million$301 million–$400 million$401 million–$500 million$501 million–$700 million$701 million–$900 million$901 million–$1.1 billion$1.1 billion–$1.3 billion$1.3 billion +You pay: $3,500You pay: $4,500You pay: $6,500You pay: $7,500You pay: $8,500You pay: $10,500You pay: $17,000You pay: $30,000You pay: $65,000You pay: $100,000You pay: $170,000You pay: $220,000You pay: $270,000You pay: $320,000You pay: $370,000You pay: $400,000You pay: $450,000You pay: $450,000 + $50,000 per $200 million above $1.3 billionPlease fill in total Net Revenue if it is higher than $1.3 billion: Personnel Employee 1Position Name First Last Employee 2Position Name First Last Email Employee 3Position Name First Last Email Employee 4Position 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 Facilities01234 Facility 1Facility 1 Name Facility 1 Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Facility 1 Website Facility 1 Email Facility 1 Chief Exectuvie Officer Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Facility 1 Chief Executive Officer Email Facility 2Facility 2 Name Facility 2 Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Facility 2 Website Facility 2 Email Facility 2 Chief Exectuvie Officer Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Facility 2 Chief Executive Officer Email Facility 3Facility 3 Name Facility 3 Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Facility 3 Website Facility 3 Email Facility 3 Chief Exectuvie Officer Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Facility 3 Chief Executive Officer Email Facility 4Facility 4 Name Facility 4 Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Facility 4 Website Facility 4 Email Facility 4 Chief Exectuvie Officer Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Facility 4 Chief Executive Officer Email Submitted ByName* First Last Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. [/vc_column_text][/vc_column][/vc_row]
