DCBHA Membership 2024
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Email *
Please provide your organization's name *
Please provide the first and last name of your organization's primary contact. This individual is authorized to vote or otherwise take official action for your organization in DCBHA membership official business matters. *
Please provide the email address for your organization's primary contact. This must be an email address assigned to a specific individual and not a generic email address like business@abc.com or admin@xyz.org. *
Please provide the name of your organization's secondary contact. This individual is authorized to vote or otherwise take official action for your organization in DCBHA membership official business matters. *
Please provide the email address for your organization's secondary contact. This must be an email address assigned to a specific individual and not a generic email address like business@abc.com or admin@xyz.org.
 *
Please provide the current physical street address of your organization's principal place of business in the District. *
Please provide the zip code of your organization's principal place of business in the District. *
Please provide your organization's federal tax identification EIN number. *
Please provide first and last names and unique email addresses for anyone else your organization wants to add to DCBHA's calendar invitations and email distribution lists by emailing Mark.LeVota@DCBehavioralHealth.org.
New members or members that need to make updates, please provide your organization's full legal name or DC-registered D/B/A (if different from above), mailing address (if different from street address), year of incorporation, for-profit or non-profit status, and DC CBE status. Again, renewing members only need to provide any updates. New or renewing members can also send this information directly to Mark.LeVota@DCBehavioralHealth.org.
How many people did your organization provide DC behavioral health services in the past year (January 2023 - December 2023, or most recent 12 month data available)? *
What is your organization's DC behavioral health budget for 2024, to the nearest $500,000? Under $500,000, round to the nearest $100,000. Do not include a dollar sign. *
Please select the dues range for your organization's DC behavioral health budget for 2024. *
Which of the following would be helpful to process your organization's 2024 dues?
An invoice will be emailed to your primary contact and secondary contact. If the invoice should be sent to someone other than the primary and secondary contacts, please provide the first name, last name, and email address of anyone who should receive a copy of the invoice.
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