NLBHA Affiliates Charter Application

The National Latino Behavioral Health Association (NLBHA) Board of Directors establishes this chartering policy to ensure consistency, mission alignment, and support for organizations seeking to become NLBHA Affiliates. Affiliates are expected to uphold NLBHA’s values, mission, and commitment to behavioral health equity in Latino communities.

A one-time Affiliate Application fee of $250.00 covers the administrative costs associated with processing new affiliate applications, management of Affiliate profiles.

Upon submission of the application, you will be redirected to the NLBHA Affiliates page.

Organization Information

Organization Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Website / URL

Facebook Name/URL

LinkedIn Name

Primary Contact Name

First

Last

Primary Contact Email

Organization Mission Statement

Eligibility

Eligibility Confirmation (Must Select All)

Our organization is one of the following: Public Agency, Private Company, or Non-Profit.
Our mission aligns with NLBHA’s mission to improve behavioral health outcomes.
We are committed to culturally responsive and evidence-based practices.
We agree to maintain transparency in our operations and financial practices.
Agency is a Hispanic Serving Organization and/or a Hispanic Led Organization.

Which Organization Type Best Reflects Your Organization

Public Agency
Private Company
Non-Profit

Affiliate Fee Structure

Initial Application Fee

Purpose: A one-time Affiliate Application fee of $250.00 covers the administrative costs associated with processing new affiliate applications, management of Affiliate profiles.

Organization Annual Operating budget and Annual Affiliate Fee Structure (subject to annual review)

Tier 1: Small Organizations ($0 to $100K): Annual/Renewal Fee $250
Tier 2: Medium Organizations ($101K – $500K): Annual/Renewal Fee $500
Tier 3: Large Organizations ($501K – $999K): Annual/Renewal Fee $750
Tier 4: ($1 million – $1.5 million) Annual/Renewal Fee $1,000
Tier 5: Above $1.5 million – Annual/Renewal Fee $1,500

Rational: This tiered structure allows smaller, grassroots organizations to participate without a prohibitive cost, while larger organizations contribute more in line with their higher resource and established capacity.

Required Documentation

Submit all attachments as one combined PDF document. If you have any issues completing this form, you may submit the completed application along with the required documentation to susiev@nlbha.org.

Please attach the following documents to verify your organization’s eligibility:

Proof of non-profit status (e.g., IRS 501(c)(3) determination letter or equivalent).
Articles of Incorporation or equivalent governing documents.
Most recent audited or unaudited annual financial statement.
Organizational chart.
Current strategic plan and Annual Report (if available).
List of current Board Officers and board of directors.
Copy of Secretary of State Good Standing certificate.

File Upload

Drag & Drop Files, Choose Files to Upload

Submit ONE combined PDF document.

Program and Partnership Information (copy)

Describe how your organization’s work aligns with NLBHA’s mission and vision (200-300 words)

Provide an example of a culturally responsive program or initiative your organization has implemented, developed, or adapted you are most proud of (200-300 words)

List key partnerships or collaborations your organization has been part of serving Latino populations

URL Percent of

Identify the areas where your organization seeks support through affiliation (check all that apply)

Organizational Commitment

Total Number of Employees:

How many are full-time?

How many are part-time?

Number or Percent of Spanish Speaking Employees

Total Number of Student Interns

Total Annual Operating Budget

Number or Percent of Staff Who Identify as Hispanic

Number or Percent of Clients/Patients/Participants Served by Our Agency Who Identify as Hispanic

Number or Percent of Board of Directors/Officers Who Identify as Hispanic (copy)

Acknowledge Responsibilities as an Affiliate (Must Select All) (copy)

We agree to uphold the mission and values of NLBHA.
We agree to participate in collective impact initiatives as outlined in the Affiliate Charter.
We agree to provide programmatic and outcome data to contribute to collective impact reporting.
We agree to sign up for NLBHA’s Juntos Network (a free communication hub for NLBHA affiliates and national networkers) to promote the Affiliates’ work and accomplishments.
We agree to participate in periodic Affiliate meetings (virtual and/or in-person at the annual NLBHA conference or other convenings).
We agree to renew our annual Affiliate dues on our anniversary date of certification.

Certification and Signature

I certify that the information provided in this application is true and accurate to the best of my knowledge. I acknowledge that the submission of this application does not guarantee acceptance as an Affiliate.

Authorized Representative Name

First

Last

Title

Enter Today's Date (mm/dd/yyyy)

Signature

Clear Signature

By signing your name, you agree that the content provided is true and accurate to the best of your knowledge.

Applications will be reviewed within 30 days of submission, and applications approved will be notified of Certification of Affiliate status.