Join the National Coalition

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

Telephone:

1-866-8-COALITION (1-866-826-2548)

or 1-631-979-5307

Fax:

1-631-979-5293

Direct E-mail to:

Kathleen Saccardi, Office Manager, at NCMHPC@aol.com

We can build a better health care system!

webmaster@TheNationalCoalition.org

Click below to donate to our discretionary fund. We will use this as we see fit.

(credit cards accepted)

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

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