To the Applicant:

Thank you for your request for organizational membership in the Outdoor Behavioral Healthcare Industry Council (OBHIC). We appreciate your interest and the spirit of collaboration and learning that led to your desire to join OBHIC. We trust that together we can work to achieve a standard of safety and excellence that will benefit both council members and those they serve.

Application Directions:

  1. Complete the attached application.
  2. Please attach a copy of the following to your application:

Your state licensing or certification

Promotional material from your program

Organizational chart

Title page of insurance

Copy of land use and other permits

3. Email or mail the completed application and attachments to:

Tara Stireman, OBHIC Membership Committee

c/o Elements Wilderness Program

P.O. Box 1166

Huntington, UT 84528

All applicants are subject to review by the membership review committee and final majority vote of the OBHIC membership.

Membership Dues:

1.OBHIC Annual Membership Dues

  • Determined annually by a majority vote of the membership
  • Fluctuate year to year depending on the organization’s priorities
  • Billed from January to December of calendar year
  • There is a “Low Census Program Dues Reduction” equal to 50% reduction for programs with fewer than 2,500 service days, and a 25% reduction for programs with fewer than 5,000 service days.

2.Research Dues

  • Depends largely on the number of member programs
  • Funds the work of OBHRC, the independent research arm of OBHIC based at the University of New Hampshire
  • Billed from July 1 through June 30 of the following year (Fiscal Year)

Membership Application

Please type or print in black ink.

Name of Organization:

Previous Organization Names, if any:

Date Founded:

Admissions Phone: Fax:

Field Office Phone: Fax:

Executive and/or Program Director:

Average Length of Stay:

Credentials (use additional page if necessary):

Direct-Care Staff:

Clinical/Professional Staff:

Management:

Training Required for Direct-Care Staff:

Student Population Sex/Age Range:

Student Capacity:

Legal Entity Orientation (non-profit/for-profit, etc):

Admissions Criteria:

State Program Licensed by:

Academics Licensed/Accredited by:

Academic Credit Given: Y/N If yes, how many?

Program Model:

Program Description:

Facilities, location, size, characteristics:

3rd Party Payment Options:

Psychotropic Medication Allowed? Y/N Please Explain:

Tuition:

Parent Organization and Address:

Primary Source of Referrals:

Application Checklist

(For internal use only)

☐Completed Application Form

☐State Licensing or Certification

☐Program Promotional Material

☐Organizational Chart

☐Title Page of Insurance

☐Copy of Land Use and Other Permits

I certify that the membership application for______(name of organization) is complete and I recommend approval for a one-year provisional membership by the OBHIC Peer Review Committee.

Signature:______

Chairperson of the Membership Committee