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Not-For-Profit Organizations Membership

Not-For-Profit Organizations Membership Form

ADDITIONAL OFFICES: YesNo

The MHAW does not share the names of its members with any other organization.

Not-For-Profit Membership (includes website listing) $550 Annual Fee


Member Information: (Please provide MHAW with any brochures, material or additional information regarding your services.)

PROFESSION*: PsychiatristSocial WorkerMHCPsychologistNurse PractitionerCASACOther
POPULATIONS(S) SERVED*: InfantsChildrenAdolescentsAdultsElderly, Age Range:
MODALITY*: IndividualCouplesFamilyGroupHomebound Services
THERAPEUTIC APPROACH:
EXPERTISE W/ SPECIFIC POPULATIONS:
FREE CONSULTATION: YesNo
EVALUATIONS: YesNo If yes, please list type:



Insurance Information:

SLIDING SCALE: YesNo
MEDICARE: YesNo
MEDICAID: YesNo
ACCEPTED INSURANCE:


Check Areas of Practice and Expertise (Limited to Six Categories for website listing)

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What areas of need have you identified in our community?

What mental health issues are important to you?

Would you like to learn more about any of our programs and services? (check all that apply)

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