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Indiana Council of Community Mental Health Centers (Indiana Council)

Home / Member Application – 2023

Member Application – 2023

Reasons to Join Membership Tier Structure

If you are employed by one of our 24 CMHC’s, you do not need to apply for a individual membership, as you are already a member as an employee.
If you are wanting to gain access to our members only page please contact your CMHC admin. If you are unsure who your CMHC admin is please reach out to Lee Ann Jordan at ljordan@indianacouncil.org
If you are a non-CMHC please reach out to Denise Wade at dwade@indianacouncil.org

Please complete the required information requested here. Required information have the * next to them.

Name *

First

Last

Job Title *

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Phone *

Email *

Organization Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Organization Website/URL *

Membership Type *

Individual
Organization

Services Provided *

Inpatient
Outpatient
Clubhouse
Group homes
Substance use disorder services
CCBHC
FQHC
Youth Residential Treatment Provider
Foster Care Agency

Primary Service Area *

Population Served *

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Is the organization incorporated as an Indiana non-profit? *

Yes
No

Is the organization tax exempt as a 501(c)(3)? *

Yes
No

Federal Employer Identification Number (FEIN) *

Operating 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 MB

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