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By becoming an organizational member of the Latino Behavioral Health Coalition (LBHC), you are joining a community dedicated to enhancing the behavioral health and well-being of Latinos globally.

Our mission, rooted in cultural understanding and respect, aims to dismantle systemic barriers to mental health care. Your membership will empower us to expand our initiatives, including educational webinars and recognition programs, creating a more informed, empathetic, and proactive approach to mental health within our communities. Together, we can build a stronger, healthier future.

Organization Information

I am applying for

Organization Name

Address

City

State

ZIP

Contact Name

Contact Title

Contact Email

Contact Phone

Website

Year Established

Annual Revenue

Organization Background

Mission Statement:

Description of Services and/or Programs Offered:

Primary Population Served:

Geographical Area Served:

Organizational Structure

Organization Type

Number of Employees

Annual Operating Budget

Primary Funding Sources

Membership Information

Reason for Joining LBHC:

Expected Contributions to LBHC (e.g., expertise, resources):

Areas of Interest within LBHC:

Any additional information you'd like considered:

Agreements and Certifications

Commitment to LBHC’s Mission and Values:

I hereby affirm that [your organization name will appear here] is committed to supporting and advancing the mission and values of the Latino Behavioral Health Coalition. We understand the importance of working collaboratively to improve behavioral health services and outcomes for Latino communities. Our organization pledges to actively participate in and contribute to the Coalition's initiatives and to uphold its principles of equity, inclusivity, and cultural competence in all our endeavors.

I agree

Data Sharing and Privacy Agreement:

[Your organization name will appear here] agrees to responsibly share and handle data in accordance with the Latino Behavioral Health Coalition's guidelines and policies. We commit to maintaining the confidentiality and security of any shared information, using it solely for the purposes of collaboration and improvement of services within the scope of LBHC activities. We understand our responsibilities regarding data privacy and agree to comply with all applicable laws and regulations pertaining to data protection and privacy.

I agree

Authorization & Certification Statement:

By submitting this application, I certify that I am authorized to apply for membership on behalf of [your organization name will appear here] and that all information provided is accurate and complete. I understand that false or misleading information may result in denial or termination of membership.

I acknowledge that this submission serves as my electronic signature, legally equivalent to a handwritten signature. I agree to abide by the terms, policies, and membership guidelines of the Latino Behavioral Health Coalition.

I understand that membership approval is subject to review and is not guaranteed.