Full Name

E-mail

 

Only update this contact information if something has changed. 

Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Fax number
Home Phone
URL

Professional Information:

Your professional title: (Choose all that apply)

          Not a Professional (please provide details below) Registered/Licensed Dietitian Licensed Professional Counselor Licensed Social Worker Psychiatrist Nurse/Nurse Practitioner Student supervised by one of the above Other (include title below) Licensed Marriage & Family Therapist Psychologist Physician      

If you answered "other" to title please provide details:

Please answer the following and attach a separate word file if any answers need explanation.

Have you ever been convicted of a misdemeanor or felony?

        Yes    No

Do you have any pending misdemeanor or felony charges?

        Yes    No

Have you ever been publicly reprimanded or disciplined by a professional licensing agency or board or are you aware of any pending investigations or complaints?

        Yes    No

Has your professional liability insurer ever placed conditions or restrictions on your coverage or ability to obtain coverage?

        Yes    No

Are you aware of any potential malpractice suits that may be filed against you?

        Yes    No

Please mail any additional documentation with comments, if needed, to the membership committee chair- Linda Sinnott.

Please select your level of Membership:

Professional ($50)        Student/ Other Professional ($25)

*Other Professional refers to a member who will not be listed on the website.

Additional Notes:

*you will be instructed about where to send your check on the next page.

*If you need to make changes to your professional listing or your group listing on this website, please contact the web coordinator- Sara Weber OR if you have questions about using BaseCamp. Sara Weber.