Behavioral Health Alliance of Montana Membership Signup
Membership open to Service Provider Organizations who are licensed/certified under State, Federal or Tribal criteria.
Organization Name *
Organization Address *
Contact Person *
Title *
Email Address *
Phone (Office) *
Our Organization Provides Mental Health Services
Check all that apply
Our Organization Provides Addiction Services
Check all that apply
Populations Served
Check all that apply
Number of Full-Time Employees
Number of Part-Time Employees
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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