NYS CCBH Provider Membership Application
Annual Membership Dues are calculated based on each of your agency’s total children's mental health budgets based on services below. Please check off the services provided by your agency. Please calculate your total children’s mental health budgets, per service area, as reported on your most recently filed CFR.

Agency dues are calculated based on the total mental health budget per the ranges outline in the chart below. Please note: The Coalition may verify services and total expenditures per CFR available information.

Please direct all questions to info@ccbhny.org.
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Services Provided *
Required
Organization Contact Information
Organization Name *
Executive Director/CEO Full Name *
Executive Director/CEO Title *
Executive Director/CEO Email Address *
Main Address *
Please include street address, city, state and zip code.
Main Phone Number *
Organization Web Address *
Billing Contact Information
An invoice for annual membership dues will be sent to the physical and email address included below. Skip this section if the invoice should be sent to the information included above.
Billing Contact Full Name
Billing Contact Email Address
Billing Contact Title
Billing Address
Please include street address, city, state and zip code.
Organization Primary Contact
For all CCBH related items, who will be the primary contact for your organization's membership. *
Primary Contact Full Name
Primary Contact Email Address
Primary Contact Phone Number
Choose your dues amount based on the chart below. *
Captionless Image
I understand that an invoice for the annual dues amount chosen above will be sent to the physical and email addresses included above upon verification. Membership benefits will begin upon receipt of payment. *
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