NCMHPC

National Coalition of Mental Health Professionals and Consumers, Inc.


an educational foundation and advocacy organization serving mental health consumers and professionals

 
 

By pressing the PRINT button on your web browser, you may print these pages and mail them to the National Coalition. (Click here for printer friendly pages.) Alternately, you may fax this application with your credit card number and expiration date to (631) 979-5293 or you may copy your information and then paste it into an e-mail message. To pay for your membership please call us at 1-866-8-COALITION with your credit card information and tell us that you e-mailed us your information.  Or you can pay us via PayPal right now.  Please do not wait - send in your information now and call us with your credit card information or click on the PayPal button.  We are depending upon you to help us help America have the privacy and the mental health system our great country deserves!

 

YES! I want to join the National Coalition of Mental Health Professionals and Consumers, Inc.

Date:               

Name:

Address:

City:

State:

Zip:

Office Ph:

Home Ph:

Fax:

Cell Ph.

E-mail:

Please check all that apply:

___   I am a Consumer? 

___   I am a Student? 

___   I am a Professional?

Discipline

Degree  

Specialty

            I am an Elected Official     What Locality

            I am Clergy 

            I am Other (please list) 

Membership:
_____  $1 - $35 Student or Consumer who can not afford the regular fees
_____  $35 and up  Student and Consumer 
_____  $100 and up  Professional Member 
_____  $35 - 99    supporter
_____  $100 - 175  advocate - minimum for Professionals
_____  $176 - 250  challenger
_____  $251 - 500  reformer
_____  $501 - 1000 leader
_____  $1001 - 2,500 champion
_____  $2501 - 5,000 hero
_____  $5001 - 10,000 super hero
_____  $10,000+ Angel

This dues payment is not deductible as a charitable contribution but may be deductible as a business expense. Please check with your tax professional on this issue.

We need your help! Please check any of the following areas of participation that interest you:

_____  Membership
_____  Media/Public Education
_____  Writing/Editing
_____  Legislative Action
_____  Phone Tree
_____  Legal
_____  Fund raising
_____  Consumer

Make checks payable to NCMHPC, Inc. and mail
together with this form to:
The National Coalition of Mental Health
Professionals and Consumers, Inc.
P.O. Box 438, Commack, New York, 11725-0438

To Fax a credit card payment enter information below and fax to: 631-979-5293

We Accept Visa, MasterCard & American Express

Type of Card        ___Visa                   ___ Master Card           ___  American Express

Card Number _____________________________________________________       Exp _______ 

Name on Card  ________________________________________________________________

Signature  ____________________________________________________________________

 

Join the efforts to restore an ethical, confidential
health care system for professionals and patients.

 
 
 
 
 
 
 
 
 

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Address: 

The National Coalition of Mental Health Professionals and Consumers, Inc.

P.O. Box 438

Commack, New York, 11725

We can build a better health care system!

webmaster@TheNationalCoalition.org

 

 

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