Individuals with lived experience of mental illness (consumers are eligible for free Primary Membership. If you identify as a consumer do not complete this form. Instead, complete a Primary Membership Application.

Contact details (Your name and at least on contact address/email is required)


Organisation/groupIndividual (eg. Carer)


Contact Person
Title
MrMrsMsMissOther (please specify)



Address



Postal address (if different)










Communication preferences
What is the best way for us to contact you?
EmailHome/Work PhoneMobile PhoneSMSPost

Do you want to receive newsletters and other information?
Yes by emailYes by post

How should we send information about AGM's and other major events?
Home/Work addressPostal addressEmail

Annual Contributions
In order to support the Network's core programs and enable beneficial relationships with like-minded organisation and groups there is a small annual contribution per organisation/group or individual.

Individuals who hold a concession card are not required to pay the contribution. Organisations/groups and individuals who feel they are unable to pay their contribution may be eligible to request a contribution waiver or reduction.

Organisation/Group Annual Funding Level and Contribution Rate
< $100,00 ($60.00)> $100,00 ($120.00)

Individual
Concession (Free) Please upload a copy of your current concession card here (jpeg, png, pdf and docx file types acceptable)
Non-concession ($25.00)

Payment methods
Cheque Please make your cheque out to ACT Mental Health Consumer Network
EFT Account Name: ACT Mental Health Consumer Network Account Number: 10168614 BSB: 062-919

Than you for taking the time to complete and submit this information.