New Member Form

Become a NACBHDD Member

Federal ID: 52-2128967
NACBHDD membership is a calendar year membership that runs from January 1- December 31. Membership is organizational; individual members are not required to join separately. Dues are calculated based on county population. Organizations covering more than one county should include all counties.

Organization Details

Organization Name

Member Category

Member Sub Category: Dues are calculated based on county population. Organizations covering more than one county should include all counties.

Membership Status:

Active

Inactive

Pending

Organization Phone

Phone Ext.

Fax

Counties

Population Servered

Services Provided

Mental Health

Substance Abuse

Developmental Disabilities

Organization Role:

Direct Provider

Authority

None

Is Exempt From Dues (For internal use only)

Organization Address

Address 1

Address 2

City

State - Country

Postal Code

Country
This field is populated by the state drop down.

Organization Primary Contact

Prefix

First Name

Last Name

Suffix

Title

Alternate Email

Phone

Phone Ext

Mobile Phone

I do not want to receive emails from NACBHDD

Payment Method:

Pay online now with a major credit card securely and easily with PayPal

Mail a Check or Credit Card payment.

To submit additional staff contacts, send an email with Your Organization Name and the First Name, Last Name and email address of the people you would like to add to: inquire@nacbhd.org