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
Explanation of Effective Date
Date facility began providing substance abuse and/or mental health treatment services
2. FACILITY INFORMATION:
Explanation of Facility Information
The first line of the facility name should include the corporate name (if applicable) or highest-level name of the facility. When applicable, line 2 of the address should include a unit or program name that uniquely identifies the facility.
* Facility Name (1):
Facility Name (2):
* Street Address (1):
Street Address (2):
* Zip Code:
Check if Mailing Address is same as Facility Address
Mailing Street Address (1):
Mailing Street Address (2):
Website Address (URL):
3. SERVICES PROVIDED (check all that apply, choosing at least one):
Explanation of Service Provided
Check all services, both substance abuse and mental health, that are provided at the street address specified on this application form.