Members Registration

The NNED invites organizations and agencies addressing mental health or substance use disparities, with a strong focus on diverse communities, to join the NNED as a Partner. Please complete this registration form to indicate your interest. Please Contact us if you need assistance.

Personal Info

First Name*

Last Name*

Email*

Your Title

User Name* (for logging in)
(no space character allowed;
email address may be used)

Screen Name* (your full name or an alias)

Your Direct Phone Number*

Your Degree

Purpose for Registration

Select one*:
  My organization would like to become a NNED partner
  My organization is currently a NNED partner, and I'd like to sign up as an individual NNED affiliate
  I would like to become a NNED affiliate (individual membership)

About Your Organization

note: if you are signing up for individual membership and are not currently working under an organization or organization, please skip this section and continue to Population Of Focus section below.

Name of Your organization

Department or Division (if applicable)

Organization Address

City

State

Zip Code

Organization Phone Number (000 000-0000)

Web Site URL

Which best describes your organization type?

Select your organization's level of focus

Select the number of employees in your organization

Brief description of oganization in 2-3 sentences

Organization's mission statement or primary area of focus

List specific strategies or interventions your organization is using to address disparities and equity in behavioral health and health

Type of Organization & services

Administrative (provides or conducts advocacy, evaluation, oversight, program development, research, education/training, or technical assistance)
Direct Service (provides outreach, education, case management, mental health and/or substance abuse treament)

Population Of Focus

Primary Population Of Focus*

Indicate your PRIMARY population of focus (select one). Data to be depicted on the NNED's Geomap. Select "Multiple Populations of Focus" if necessary.

Population Of Focus Detail

Provide more detail about your population(s) of focus by writing in specific groups that your organization serves. This help us tailor our outreach, make specific requests for NNED involvement, and share resources. Please separate groups by commas.

For example, provide name(s) of tribes, specific ethnic groups (e.g., Filipino, Pakistani, Samoan, Haitian, Puerto Rican, Mexican American), refugee countries of origin, etc. The more detail the better!

(provide description in this box)
Population Focus Detail

Languages

Indicate the language(s) and language services your organization provides (other than English):

Spanish
Chinese
Telephonic Interpretor Services
On-site staff translation
Other

Geographical Community

Select the geographical community of your population of focus:

Urban
Rural and/or Frontier
Suburban
Reservation

Age Range

Select the age ranges of your population of focus:

Early Childhood (0-5)
Childhood (6-12)
Adolescent (13-17)
Young Adult (18-25)
Adult (26-55)
Older Adult (55+)

Outreach

Indicate all of the NNED services that would be useful for your organization:

Peer Technical Assistance
Webcast and Webinars featuring best practices
In-person meetings
Collaboration with NNED partners
Involvement in special projects
Monthly newsletter (NNED Note)

Create a Password

Password*

Re-type Password*

A few more things...

How did you first hear about the NNED?

For security purpose, please type the test word you see below:

Enter test word* →

By submitting this form, you agree to accept the NNED's guiding principles as stated on the NNED website*.

Thank you for your interest in the NNED! Access to secured areas of NNED web site will be granted after application approval. Your account will be activated within 48 hours and you will be notified by email.