Membership Application Form

MHA Membership Application for Mental Health Professionals

Questions? Contact Andrea Towner at atowner@mhacentralcarolinas.org or call 704-365-3454 ext 223.
Name (Individual or Group)
Contact Person for Group Membership
Salutation
Professional Credentials
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail
Phone Number

Area Code Phone Number
Mobile Phone Number

Area Code Phone Number
Website
Please upload a copy of your current licensure/ certification
Professional liability insurance with minimum coverage of $1,000,000/ $3,000,000 or $2,000,000/ $2,000,000 is required. Upload a copy of the policy cover sheet.
I serve the following consumer/client populations (check all that apply.)

Toddlers/Preschoolers Child Adolescent Young Adult Adult Geriatric Family Athletes First Responders LBGTQ Veterans Immigrants & Refugees
Problems/disorders treated (choose only TOP SIX treatment areas.)

Acute care for immediate hospitalizations Adjustment disorders Anxiety disorders Attention deficit disorders Autism/ Asperger's Bipolar disorders Co-dependency Communication/ relationship skills Crisis intervention Depressive disorders Dissociative disorders Eating disorders Emotional trauma Family therapy/ parenting Forensic evaluations LGBT issues Grief/ bereavement Impulse disorders Intellectual/ developmental disorders Life balance/ personal growth Marital relations/ divorce Neuropsychology Obsessive-compulsive disorder Obesity/ weight management Personality disorder Post-traumatic stress disorder Psychological assessments Schizophrenia/ psychoses School issues Self-injury Sexual/ physical abuse Sexuality/ sexual dysfunction Somatoform disorder/ chronic pain Sports mindfulness/ training Substance abuse
Fee structure (check all that apply.)

My services can be covered by insurance. I accept direct assignment of benefits. I offer sliding scale fees for services. I participate in managed care networks.
Insurance types you accept (check all that apply.)

Aetna Life Insurance Company Aetna Health, Inc. All Savers Insurance Co. Blue Cross Blue Shield of NC Champus/ TRICARE CIGNA Health Coventry Health and Life Insurance Co. Coventry Health Care of the Carolinas Federated Mutual Insurance Company First Access First Health Humana John Alden Life Insurance Company Magellan Behavioral Health MedCost Preferred Medicaid Medicare National Foundation Life Insurance Co. Private HealthCare Systems Time Insurance Company United Behavioral Health United HealthCare Contact provider for details
Has there been any event which triggers any of the reporting requirements described in MHA's attestation requirements? If so, please send an explanation and describe the current status and findings of any investigations or proceedings. *

I have nothing to report. All reportable matters are described and, upon request, I agree to provide releases for Mental Health America of Central Carolinas to secure materials from any parties having knowledge of these matters.
Signature
Signature date
Membership Type

Individual Membership $100.00 Group Membership $250.00
I would like to participate in MHA's Connecting Voices focus group for members?

Yes No Send me more info
Payment is not currently accepted on this form. Go to www.mhacentralcarolinas.org and click "Donate" to make your payment online. Or, mail payment to MHA at 3701 Latrobe Drive, Suite 140, Charlotte, NC 28211.
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MHA Membership Application for Mental Health Professionals

Payment is not currently accepted on this form. Go to www.mhacentralcarolinas.org and click "Donate" to make your payment online. Or, mail payment to MHA at 3701 Latrobe Drive, Suite 140, Charlotte, NC 28211.