Provider Membership Application

    Thank you for your interest in a New York Alliance membership. We ask that you provide us with information about your provider organization so that we may be a strong and respected advocate for your organization and the people you support. Our strength is found in the diversity and depth of our member organizations. Your membership enables New York Alliance to build strong coalitions and engage key stakeholders to advocate for all people with disabilities. For all membership related matters, please contact Lisa Mount at [email protected] or by calling 518-795-3590.

    Primary Contact Information

    Agency Services Provided

    Check all that apply.
      Article 16 Clinic
      Article 28 Clinic
      Article 31 Clinic
      Community Habilitation
      Day Habilitation
      Family Care
      Family Support services (FSS)
      Individual Residential Alternative
      Individual/Community Support (ISS/CSS)
      Intermediate Care Facility
      Self-Directed Services-Fiscal Intermediary
      Self-Directed Services-Broker
      Self-Directed Services-Shared Living
      Self-Directed Services-Paid Neighbor
      Employment Services
      Primary Medical Services
      Private School
      Sheltered Workshop
      Skilled Nursing
      HARP-Health & Recovery Program

    Other Services / Additional Information

      CQL Accredited
      Leadership Institute Graduates
      Care Coordination Organization(s) Affiliation
      National Affiliation(s)

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