Membership Application Form

MHA Membership Application for Mental Health Professionals

Questions? Contact Andrea Towner at atowner@mhaofcc.org or call 704-365-3454 ext 223.
Name (Individual or Group)
Contact Person for Group Membership
Salutation
Professional Credentials
(i.e., Psy.D.)
Professional Title
(i.e., Psychologist, etc.)
Practice Name
(if applicable; if not, leave blank)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number

Area CodePhone Number
Mobile Phone Number

Area CodePhone 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/PreschoolersChildAdolescentYoung AdultAdultGeriatricFamilyAthletesFirst RespondersLBGTQVeteransImmigrants & Refugees
Problems/disorders treated (choose only TOP SIX treatment areas.)

Acute care for immediate hospitalizationsAdjustment disordersAnxiety disordersAttention deficit disordersAutism/ Asperger'sBipolar disordersCo-dependencyCommunication/ relationship skillsCrisis interventionDepressive disordersDissociative disordersEating disordersEmotional traumaFamily therapy/ parentingForensic evaluationsLGBT issuesGrief/ bereavementImpulse disordersIntellectual/ developmental disordersLife balance/ personal growthMarital relations/ divorceNeuropsychologyObsessive-compulsive disorderObesity/ weight managementPersonality disorderPost-traumatic stress disorderPsychological assessmentsSchizophrenia/ psychosesSchool issuesSelf-injurySexual/ physical abuseSexuality/ sexual dysfunctionSomatoform disorder/ chronic painSports mindfulness/ trainingSubstance 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 CompanyAetna Health, Inc.All Savers Insurance Co.Blue Cross Blue Shield of NCChampus/ TRICARECIGNA HealthCoventry Health and Life Insurance Co.Coventry Health Care of the CarolinasFederated Mutual Insurance CompanyFirst AccessFirst HealthHumanaJohn Alden Life Insurance CompanyMagellan Behavioral HealthMedCost PreferredMedicaidMedicareNational Foundation Life Insurance Co.Private HealthCare SystemsTime Insurance CompanyUnited Behavioral HealthUnited HealthCareContact 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 $100.00Group Membership $250.00
Payment is not currently accepted on this form. Go to www.mhaofcc.org and click "Donate" to make your payment online. Or, mail payment to MHA at 3701 Latrobe Drive, Suite 140, Charlotte, NC 28211.
Should be Empty:

MHA Membership Application for Mental Health Professionals

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