Membership Application / Renewal Form

Checks should be made out to MiBAP.

Please send your check to:

Michigan Behavior Analysis Providers (MiBAP)
13134 N. Lewis Rd.
Clio, MI 48420

Questions? Contact Us at membership@MiBAP.org

MIBAP Membership Application/Renewal Form

PROFESSIONAL INFORMATION

Facility Name(Required)

Facility Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Website

Office Phone(Required)

Primary Contact Name(Required)

First Last

Primary Contact Professional Title(Required)

Primary Contact Email(Required)

Secondary Contact Name

First Last

Secondary Contact Professional Title

Secondary Contact Email

Please list the counties of Michigan you serve.

Tell us a little about your facility:

MEMBERSHIP CATEGORY

MiBAP membership dues are determined based on annual ABA services revenue in the state of Michigan. Dues cover membership for a one-year period.

Select a Membership Tier(Required)

Active Member - NEW: In business for less than 18 mo's. | $1,000/YR Dues

Active Member - TIER 1: Less than $1M Annual ABA Services Revenue in MI | $2,000/YR Dues

Active Member - TIER 2 $1M - $3M Annual ABA Services Revenue in MI | $3,000/YR Dues

Active Member - TIER 3 $3M - $5M Annual ABA Services Revenue in MI | $4,000/YR Dues

Active Member - TIER 4 Over $5M Annual ABA Services Revenue in MI | $6,000/YR Dues

Affiliate Member $500/YR Dues

Individual Affiliate Member $250/YR Dues

MEMBERSHIP AGREEMENT & ATTESTATION

PLEASE READ AND AGREE (Active Members Only)

Our facility meets the criteria for active membership as described above. We subscribe to the purposes of MiBAP and agree to be abide by its bylaws. Further, I attest to the following on behalf of my organization:

1) We verify BACB certification and Michigan licensure for all behavior analysts and assistant behavior analysts

2) We follow all procedures as established by the state for QBHPs (if applicable for your organization) and they are supervised by a Michigan licensed behavior analyst

3) We perform background checks on all staff and preclude employment of anyone that does meet the requirements of payors and Michigan licensure law for behavior analysts

4) We only use W2 employees as Behavior Technicians; we do not use independent contractors (1099s)

5) We provide all payor-required training to behavior technicians prior to their independent work with clients as outlined in payor contracts

6) We have clear standards and policies for termination of services and completion of client treatment when clinically appropriate

7) We enforce internal policies that align with the standards of the current Ethics Code for Behavior Analysts and the RBT Ethics Code

Name of Person Attesting to this Membership Agreement(Required)

First Last

Title of Person Attesting to this Membership Agreement(Required)

Email of Person Attesting to this Membership Agreement(Required)

Enter Email Confirm Email

Authorization(Required)

I declare that I am duly authorized to sign to the above agreement on behalf of the organization listing in this application