Alternative Mobile Services Association Individual Membership Application
Your Name:
*
First Name
Last Name
Licensure:
No Licensure? Please write - NA.
Email Address:
*
Email
Alternate Email:
example@example.com
Agency Name:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
Membership Levels
*
prev
next
( X )
Peer & Student Membership
(
$
25.00
for each
year
)
For any current person with lived experience of mental illness, addiction, or alcoholism, or full or part-time students.
General Membership
(
$
50.00
for each
year
)
For those with a general interest in mobile crisis response.
Professional Membership
(
$
100.00
for each
year
)
For individuals licensed to provide medical or counseling service - no cost CEs from conferences.
TEST
(
$
Free
for each
year
)
Total
$
0.00
Email
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Your short bio?
Help others get to know you better.
Your agency's mission?
Help others get to know you better.
Mobile service name:
Name of the mobile outreach service in your area
Mobile service currently operational?
Yes
No
Under Consideration
Year founded?
Who operates the mobile service?
Police Department
Sheriff's Department
Hospital
Community Agency
City or County
Team staffed by?
Nurse/EMT/paramedics
General crisis workers
Peer support workers
Counselor / social workers
Law enforcement
Psychiatrist / medical doctors
Other
Serves?
Adults
Youth
All ages
Service model:
First Responders
Co-Responder
Plainclothes
Embedded Clinician
Other
Initial Contact:
911 dispatch
Police non-emergency
3-digit number
10-digit number
By police request
Request of other agency
Self-dispatch
Service provided:
Mental health care
Addiction / alcoholism care
Street-involved
Follow-up care
Medical care
Medication support
Suicide response
Will respond to weapons / risk?
Yes
No
Funding?
City / county / state budget
Law enforcement budget
Insurer budget
Medicaid
Other funding
Private philanthropy
Submit File(s)
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