Home / Member ApplicationMember Application Please complete the required information requested here. Required information have the * next to them. Please enable JavaScript in your browser to complete this form.Organization Name *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Primary Email *Organization Website/URL *Organization Head *FirstLastJob Title *Contact Person *FirstLastJob Title *Is your organization a CMHC? *YesNoServices Provided *InpatientOutpatientClubhouseGroup homesSubstance use disorder servicesCCBHCFQHCYouth Residential Treatment ProviderFoster Care AgencyMission Statement *Primary Service Area *Adams CountyAllen CountyBartholomew CountyBenton CountyBlackford CountyBoone CountyBrown CountyCarroll CountyCass CountyClark CountyClay CountyClinton CountyCrawford CountyDaviess County Dearborn CountyDecatur CountyDeKalb CountyDelaware County Dubois CountyElkhart CountyFayette CountyFloyd CountyFountain CountyFranklin CountyFulton CountyGibson CountyGrant CountyGreene CountyHamilton CountyHancock CountyHarrison CountyHendricks CountyHenry CountyHoward CountyHuntington CountyIndianapolis and Marion CountyJackson County Jasper CountyJay CountyJefferson CountyJennings CountyJohnson CountyKnox CountyKosciusko CountyLaGrange CountyLake CountyLaPorte CountyLawrence CountyMadison CountyMarshall CountyMartin CountyMiami CountyMonroe CountyMontgomery CountyMorgan CountyNewton CountyNoble CountyOhio CountyOrange CountyOwen CountyParke CountyPerry CountyPike CountyPorter CountyPosey CountyPulaski CountyPutnam CountyRandolph County Ripley CountyRush CountyScott CountyShelby CountySpencer CountySt. Joseph CountyStarke CountySteuben CountySullivan CountySwitzerland CountyTippecanoe CountyTipton CountyUnion CountyVanderburgh CountyVermillion CountyVigo CountyWabash CountyWarren CountyWarrick CountyWashington CountyWayne CountyWells CountyWhite CountyWhitley CountyPopulation Served *Is the organization incorporated as an Indiana non-profit? *YesNoIs the organization tax exempt as a 501(c)(3)? *YesNoOperating budget for most recent fiscal year $ *# of Full-Time Employees *# of Part-Time Employees *# of Board Members *# of Volunteers *Organization Logo Click or drag a file to this area to upload. Please upload your organization logo here. Format: .jpg, .png, .gif Minimum width: 500 pixels Minimum height: 260 pixels Maximum file size: 5 MBSubmit