National Association of Addiction Treatment Providers

July 5, 2008

Please fill out the form below to become a NAATP member or, if you prefer, read the membership benefits before completing the application.

NAATP Online Membership Application

You can apply for NAATP membership by completing this application and submitting it online. Thank you for your interest in NAATP! NAATP represents addiction treatment programs within and outside the U.S. NAATP represents the interests, concerns and commitments of those organizations offering addiction treatment in a wide range of settings and at various levels of treatment intensity.

Application Type:
(Please select one)

	Corporate - Organizations owning and/or managing more than one private chemical dependency treatment program. As a corporate member of NAATP, each of your affiliated programs will be entitled to full membership benefits, although voting rights reside only with the designated corporate delegate.
	Program - Single facility treatment programs.
	Associate - Vendors, suppliers, consultants, publishing organizations, marketing organizations and others. An Associate Member is not entitled to a vote, but is otherwise accorded full membership privileges and benefits.

Contact Person:
(Bylaws mandate contact person is the Owner, CEO, Executive Director or Administrator)

Name:	(required)
Title:
Facility:
Address:
Address 2:
City:
State:
Zip:
Telephone:
Fax:
Email:	(required)
Web:

Program Description:

1. Enter the number of treatment facilities/beds your organization operates:

Facilities	Beds
		Owned and directly operated by your organization
		Managed by your organization but owned by another organization
		Managed by another organization but owned by your organization

2. Please check below all of the descriptions that apply to your organization:

	Freestanding Inpatient/Residential Facility
	Freestanding Specialty Hospital
	CD Unit in General Hospital
	Psychiatric Hospital
	Outpatient (Non Residential) Facility

3. Please indicate status:

	For Profit
	Not For Profit

5. If program is inpatient/residential, do you have an affiliated outpatient program on-site?

	Yes
	No

6. Is your program:

	JCAHO accredited?
	CARF accredited?
	Licensed?

7. Dimensions of Treatment Offered: (Check all that apply)

	Inpatient Detoxification
	Outpatient Detoxification
	Primary Residential Chemical Dependency Treatment
	Extended Care/Long-Term Treatment
	Intensive Outpatient Program
	Outpatient Treatment Program
	Partial Hospitalization
	Sober Living
	Intervention
	Software Products
	Consulting
	Insurance Products
	Pharmaceuticals

8. Specialty Programs or Specialty Populations: (Check all that apply)

	Gender specific for Women
	Gender specific for Men
	Adolescent
	Sexual Addictions
	Eating Disorders
	Psychiatric Treatment/Psychological Services
	Compulsive Gambling
	Alcohol/Drug Addiction
	Medication Management

NAATP Membership Dues Structure:

This formula is based on Gross Charges for chemical dependency activity and caps NAATP dues at $12,000. This model treats multi-site/locations as one and the dues should be paid on the total for the entire operation.

Gross Charges:	NAATP Annual Dues:
Associate Member	$650.00
Gross Charges less than 1.5M	$800.00
Gross Charges 1.5M but less than 3M	$900.00
Gross Charges 3M but less than 5M	$1,300.00
Gross Charges 5M but less than 8M	$2,500.00
Gross Charges 8M but less than 12M	$4,000.00
Gross Charges 12M but less than 18M	$5,000.00
Gross Charges 18M but less than 25M	$7,000.00
Gross Charges 25M but less than 35M	$9,500.00
Gross Charges greater than 35M	$12,000.00
Please enter your yearly dues:

Membership Mailings:

We will provide the NAATP newsletter to others you designate in your organization. Please enter their names and contact information below:

Name:
Title:
Facility:
Address:
Address 2:
City:
State:
Zip:
Telephone:
Fax:
Email:
Web:

Name:
Title:
Facility:
Address:
Address 2:
City:
State:
Zip:
Telephone:
Fax:
Email:
Web:

Payment Information:

Please enter your credit card payment information in the form fields below.

Card Type :
Card Number :
Expiration Date :

Enter Verification Code:

National Association of Addiction Treatment Providers
313 W. Liberty Street, Suite 129, Lancaster, PA 17603-2748 - Phone: 717 392-8480 - Fax: 717 392-8481 - rhunsicker@naatp.org
©1999-2007 - 2008 National Association of Addiction Treatment Providers