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Behavioral Health Alliance of Montana Membership Signup
Membership open to Service Provider Organizations who are licensed/certified under State, Federal or Tribal criteria.
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Organization Name
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Organization Address
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Your answer
Contact Person
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Your answer
Title
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Email Address
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Phone (Office)
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Our Organization Provides Mental Health Services
Check all that apply
Peer Support
Outpatient
In-home Services
Inpatient/Residential (add # of beds in "OTHER")
Other:
Our Organization Provides Addiction Services
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Substance Abuse Prevention
Recovery Support
Outpatient
In-home Services
Inpatient/Residential (add # of beds in "OTHER")
Other:
Populations Served
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Youth
Adult
Women
American Indian
Criminal Justice
LGBTQ
Veterans
Racial/Ethnic Minorities
Other:
Number of Full-Time Employees
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Number of Part-Time Employees
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2020 dues are based on your FY19 Operating Budget
$ [FY19 budget] X 0.1% (.001) = $ [FY20 BHAM Dues] // min $1000, max $20,000
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