Membership Application Form Organization *Program Name (if applicable) Primary Contact *TItle *Address *City/State/Zip *Work Phone *Fax Cell Phone Email *Website Treatment Services Offered: MAT Administration/MonitoringDetoxInpatient TreatmentResidential TreatmentOutpatient Treatment Level IOutpatient Treatment Level IIOutpatient Treatment Level IIIRecovery/Transitional Housing Men onlyWomen onlyMen & WomenWomen with ChildrenMen with ChildrenCouples with ChildrenAccepts Clients Identifying as TransgenderAccepts Clients using Medication Assisted TreatmentRecovery Support Services Offered: Aftercare Support/CoachingCare Coordination/Therapeutic AftercarePeer Support or Peer NavigatorsRecovery CoachingPeer MentoringRecovery Community Center/SpaceScreening and AssessmentPrevention ActivitiesCertifications Department of Mental Health: Recovery SupportDepartment of Mental Health: OutpatientNational Alliance for Recovery ResidencesCommission on Accreditation of Rehabilitation FacilitiesThe Joint CommissionPhoneSubmit
