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*
Head 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?*
If yes, please specify
Contact Details
Member Representative Name (preferably CEO or Executive Level)*
First Last
Position*
Mobile Number*
Email*
Member Representative Proxy*
First Last
Position*
Mobile Number*
Email*
About Your Organisation
Number of staff*
Number of clients*
Service Delivery Age*
- Youth (0 - 12 years)
- Young persons (12 - 26 years)
- Adults (18 - 65 years)
- Older persons (65+)
Main Source Funding*
- NDIS
- QLD Health
- PHN
- Other Federal Government
- Other State Government
- Local Council
- Fee for Service
- Community Donations
- Philanthropic
- Other
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
Other (please specify)
Does this Organisation provide services in regional, remote or rural areas?*
Programs & Services Provided*
- Aboriginal and/or Torres Strait Islander Support
- Accommodation Support
- Alcohol & Other Drugs
- Carer Support &/or Respite
- Clinical Services - Nursing & Allied Health
- Coaching (eg CBT based programs)
- Corrections & Transition
- Counselling - Group/Individual
- Creative Arts
- Culturally and Linguistically Diverse (CALD)
- Digital Mental Health Services
- Domestic Violence
- Employment/ Work Readiness
- Financial Support
- Homelessness
- Housing Support & Tenancy
- Independent Advocacy
- Legal Service
- LGBTIQA+
- MH Awareness
- Mental Health Recovery Support (Outreach)
- NDIS
- Parenting & Family
- Perinatal
- Refugee Support
- Relationship
- Residential Rehab - Step Up Step Down/CCU
- Service Coordination
- Social Enterprise
- Suicide Prevention
- Other
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.
Previous financial year's mental health revenue*
Membership Fees (renewable annually on 1 July - GST exclusive)*
- Organisations with low income (under $100K) ($75 Membership Fee)
- 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
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New Organisation Membership Application

Organisation Details

Contact Details

About Your Organisation

Membership Fees

An invoice will be issued following confirmation of Board approval