General Membership - Queensland Alliance

Organisation Details
Organisation Type*
- Government
- Private Company
- Incorporated Association
- Not-for-Profit Organisation
- Non-Governmental Organisation
- Cooperative (Incorporated)
- Public Company
- Company Limited by Guarantee
- Community Group
Organisation Name*
Trading Name (if applicable)
ABN/ ACN*
Office Phone Number*
Website
Office Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Postal Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you have any other Offices in QLD?*
Contact Details
Member Representative Name (preferably CEO or Executive Level)*
Prefix First Last
Position*
Mobile Number
Email*
Member Representative Proxy*
Prefix First Last
Position*
Mobile Number
Email*
About Your Organisation
Number of staff*
Number of clients*
Organisation Target Population*
- 0 - 12 years
- 12 - 26 years
- 18 - 65 years
- Aged
- Aboriginal / Torres Strait Islander
- Culturally & Linguistically Diverse (CALD)
- LGBTIQ
- Non-specific / All
- Youth
Other (please specify)
Main Source Funding*
- Public fund raising
- Membership
- Fee for Service
- Community donations
- Philanthropic
- Government
- Non-funded
- NDIS
Other (please specify)
All Area(s) of Operation*
- Brisbane Metro North
- Brisbane Metro South
- Gold Coast
- Sunshine Coast
- Townsvillle
- Central Queensland
- Central West Queensland
- North West Queensland
- South West Queensland
- West Moreton
- Cairns & Hinterland
- Darling Downs
- Mackay
- Torres & Cape
- Wide Bay
Other (please specify)
Does this Organisation provide services in regional, remote or rural areas?*
Programs & Services Provided*
- Accommodation Support
- Alcohol & Other Drugs
- Carer Support &/or Respite
- Clinical Services
- Community Inclusions
- Independent Consumer Advice
- Counselling - Group/Individual
- Disability Support
- Employee/er Support
- Employment/ Work Readiness
- Financial
- Forensic Orders
- Homelessness
- Housing Support & Tenancy
- Independent Advocacy
- MH Awareness
- Peer Support
- Perinatal
- Prison & Transition
- Refugee Support
- Residential Rehab
- Service Coordination
- Social Enterprise
- Suicide Prevention
Condition Specific (please specify)
Other (please specify)
Membership Fees
Membership fee is based on previous financial year's annual mental health revenue for delivery of services within Queensland. This includes federal and psychosocial NDIS funding of these services.
Membership Fees (renewable annually on 1 July - GST exclusive)*
- Organisations with no annual income ($50 Membership Fees)
- Organisations with an annual income up to $500K ($175 Membership Fee)
- Organisations with an annual income up to $1M ($275 Membership Fee)
- Organisations with an annual income between $1M and $3M ($700 Membership Fee)
- Organisations with an annual income between $3M and $6M ($1,400 Membership Fee)
- Organisations with an annual income between $6M and $10M ($2,800 Membership Fee)
- Organisations with an annual income over $10M ($4,200 Membership Fee)
An invoice will be issued following confirmation of Board approval
Declaration*
- I have read, understand and agree with the Alliance Rules
Comments
This field is for validation purposes and should be left unchanged.

New Organisation Membership Application

Organisation Details

Contact Details

About Your Organisation

Membership Fees

An invoice will be issued following confirmation of Board approval