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

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