Form I-TF Facility Regi I-TF Facility Regi I-TF Facility Registration Application Form

4/18/23, 2:59 PM

Attachment C: Facility Registration Form

Facility Registration - FindTreatment.gov

U.S. Department of Health & Human Services

For help finding treatment: 800-662-HELP (4357)

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Facility Registration
This page provides the registration form and instructions for facilities who want to be listed on FindTreatment.gov. Listing your
facility on FindTreatment.gov will help increase the visibility of treatment services provided by your facility, enhance outreach to
your potential clients, and help SAMHSA facilitate greater access to mental health and substance use treatment services.

Please select from tabs below for application form instructions, or to complete and submit the application form.
Facility Registration Application Form

Facility Registration Application
Instructions

Facility Registration Application Form
OMB No. 0930-0386
See OMB Public Burden Statement at bottom of the instructions page.
Expiration date: 3/31/2024

Please complete this application form to request that your facility be added to FindTreatment.gov. Click here for instructions and
more information regarding this form.

* Indicates a required field.
If you prefer to print the form and submit by email or mail, please download the form

and send it to:

BHSIS Project Office
Hendall Inc.
1803 Research Blvd, Suite 300
Rockville, MD 20850
[email protected]
Questions? Call the BHSIS Project Office toll-free at 1-833-888-1553 Monday through Friday, 8:00 a.m. to 6:00 p.m. Eastern Time.
1. Facility Information 
* Facility Name (1)

Facility Name (2)

* Street Address (1)

Street Address (2)

* City

* State

* Zip Code

(select)

* County
https://findtreatment.gov/facility-registration/application-form

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Facility Registration - FindTreatment.gov

Check if Mailing Address is same as Facility Address
Mailing Street Address (1)

Mailing Street Address (2)

City

State

Zip Code

(select)

* Telephone/Extension

Fax

Director's Name

Director's E-Mail

Website Address (URL)

2. Services Provided *

(check all that apply, selecting at least one)
Substance Use Services

Mental Health Services

Treatment

Treatment

Detoxification

Administrative Services

Administrative Services

Other Non-Treatment Services

Other Non-Treatment Services

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Facility Registration - FindTreatment.gov

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1-877-SAMHSA-7 (1-877-726-4727)

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