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Behavioral Health Treatment Services Locator

I-BHS Facility application form
OMB No. 0930-0106

Please complete this application form to request that your facility be added to SAMHSA's Inventory of Behavioral Health
Services (I-BHS). Click here for instructions and more information regarding this form.

 

(* Indicates a Required Field)

1. EFFECTIVE DATE:
Close on selection

 
2. FACILITY INFORMATION:
* Facility Name (1):
Facility Name (2):
* Street Address (1):
Street Address (2):
* City: * State: * Zip Code:
* County:
Check if Mailing Address is same as Facility Address
Mailing Street Address (1):
Mailing Street Address (2):
   City:    State:    Zip Code:
* Telephone/Extension:
Fax:
Director's Name:
Director's E-Mail:
Website Address (URL):

 
3. SERVICES PROVIDED (check all that apply, choosing at least one):
Substance Abuse Services
Mental Health Services
Treatment
Treatment
Detoxification
Administrative Services
Administrative Services
Other Non-Treatment Services
Other Non-Treatment Services

 

Type the characters you see in the picture below.

Expiration date: 12/31/2018
See OMB Burden statement at bottom of the instructions page.