MHA Membership Application Form

MHA Membership Application for Mental Health Professionals

Questions? Contact Maria Johnson at mjohnson@mhaofcc.org or Kerri Seagraves at kseagraves@mhaofcc.org or call 704.502.0060.
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

Upload a File

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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.

Upload a File

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I serve the following consumer/client populations (check all that apply.)
Problems/disorders treated (choose only TOP SIX treatment areas.)

Other
Fee structure (check all that apply.)
Insurance types you accept (check all that apply.)

Other
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.
Signature
Signature date
Membership Type
Should be Empty:

MHA Membership Application for Mental Health Professionals