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.