Membership Application & Renewal Form

Please fill out the application below.
* Required fields are preceeded by an asterisk and displayed in red.

* Status

New Membership Membership Renewal

* First Name

* Last Name

Affiliation

Job Title

Highest mental health degree (list only one)

[e.g. PhD, EdD, PsyD, MSW, MS, MA, MEd]

Primary mental health credential(s)

[e.g. LP, LCSW, LPC, MFT (do not list RPT, RPT-S)]

Primary mental health discipline
(check one, perhaps based upon primary professional association)

Counseling Marriage & Family Therapy Psychology/Psychiatry Nursing Social Work Other

Other discipline

Primary mental health workplace
(check only one, perhaps based upon primary income source)

Private practice - privately owned practice; self-employed alone or with others Non-profit - religious or other community-owned nonprofit agency or organization Medical - private or public hospital or clinic Public - city, county, state, or national governmental service agency or department School - private or public; K-12 College/University - private or public; instruction, administration, research, etc. Author/Presenter - research, write, or edit publications; training presenter/consultant Other

Other workplace

Social Security Number
(last 4 digits only)

[confidential - used internally only for verification of identities]

Name of your member sponsor (If applicable)

* Location

United States Outside the US

* Mailing Address

* City

* State

Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Province

* Zip

* Country

* Phone

Fax

* E-mail

* Member Category & Dues
Non-US members are exempt from Branch dues. US members not residing or practicing in a chartered branch are also exempt from Branch dues but may voluntarily choose to join a chartered branch.

US Professional (individual mental health professional) US Affiliate (individual full-time student / other non-mental health professional) Non-US International (individual mental health professional) Non-US Affiliate (individual full-time student / other non-mental health professional)

* Branch

Select a Branch Alabama Alaska Arizona Arizona South Arkansas California Colorado Florida Georgia Georgia South Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland/DC Michigan Minnesota Mississippi Missouri Nevada New England (incl. CT, MA, NH, RI, VT) New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania South Carolina South Dakota Tennessee Texas Utah Virginia West Virginia Wisconsin Wyoming No Branch in my State

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3198 Willow Avenue, Suite 110 · Clovis, CA 93612 USA
Tel: 559·294·2128 / Fax: 559·294·2129 / E·mail: info@a4pt.org

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