Organizational Membership Form

FBHA Membership Application

Please complete the following application to be considered for membership with the Florida Behavioral Health Association.. Applications will be voted on at the next schedule meeting of the FBHA Board of Directors.
Organization Name*
CEO Name*

First NameLast Name
CEO E-mail*
Total revenue for your organization as reflected on your previous year's audit.*
CEO Cell Phone Number

Area CodePhone Number
ADMINISTRATIVE ASSISTANT Name

First NameLast Name
Administrative Assistant Email
example@example.com
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Website
ADMINISTRATIVE OFFICE PHONE NUMBER

Area CodePhone Number
Service REFERRAL Phone Number

Area CodePhone Number
Organization Logo

Browse Files

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CEO HEAD SHOT

Browse Files

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Organization Information
# of Employees
Types of services provided by your organization (select all that apply)

Adult Mental HealthAdult Substance UseChildren's ServicesResidentialOutpatientOther
Leadership Staff Information
COO Name

First NameLast Name
COO Email
example@example.com
CFO Name

First NameLast Name
CFO EMAIL
example@example.com
HR Director

First NameLast Name
HR Director Email
example@example.com
CIO Name

First NameLast Name
CIO Email
example@example.com
Clinical Director

First NameLast Name
Clinical director email
example@example.com
Should be Empty:

FBHA Membership Application