Send your application to the Alliance by completing and submitting the form below. Membership Level* Full Membership - based on agency operating behavioral health budget multiplied by 0.0016, minimum of $1500 and maximum of $12,000 Associate Membership - $1500/year Name First Last TitleOrganization NamePrimary Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFaxEmail Website Annual Behavioral Health BudgetFull membership dues are assessed based on total organization behavioral health budget multiplied by 0.0016. Minimum full member dues are $1,500/year. Maximum full member dues are $12,000/year. Associate member dues are $1500 and are not budget based.Description of ServicesPlease describe the behavioral health and other services your organization provides. Evidence of local and statewide collaborationList two (2) current AAMHS members who will sponsor your membership application: One sponsor must be from your agency's primary geographic location.Full NameFull Name