Test Price: $0.50 for 16 Days First Name:* First Name Required Last Name:* Last Name Required Address Line 1:* Address Line 1 is Required Address Line 2: Address Line 2 is not valid City:* City is Required Country:* Country is Required -- Select Country -- United States (US) Afghanistan Åland Islands Albania Algeria Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belau Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba CuraÇao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Republic of Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Norway Oman Pakistan Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Martin (Dutch part) Saint Pierre and Miquelon Saint Vincent and the Grenadines San Marino São Tomé and Príncipe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia/Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (UK) Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Western Samoa Yemen Zambia Zimbabwe State/Province:* State/Province is Required Zip/Postal Code:* Zip/Postal Code is Required Telephone Number:* Telephone Number is Required Email:* Email is Required Profession or Field of Employment:* Profession or Field of Employment is Required Highest Degree Earned:* Highest Degree Earned is Required Date:* Date is Required University:* University is Required Are you a licensed psychologist? Are you a licensed psychologist?:* Are you a licensed psychologist? is Required Yes No If you are not a licensed psychologist:: If you are not a licensed psychologist: is not valid If you are not a licensed psychologist, was your graduate program APA approved? If you are not a licensed psychologist, was your graduate program APA approved?: If you are not a licensed psychologist, was your graduate program APA approved? is not valid Yes No If you are not a licensed psychologist, did you have an APA approved internship? If you are not a licensed psychologist, did you have an APA approved internship?: If you are not a licensed psychologist, did you have an APA approved internship? is not valid Yes No Year of Licensure/Certification:* Year of Licensure/Certification is Required License Number:* License Number is Required State Issuing License:* State Issuing License is Required Have you ever been called upon to answer professional or ethical charges before an Ethics committee or any professional organization, state licensing board or court of law? Have you ever been called upon to answer professional or ethical charges before an Ethics committee or any professional organization, state licensing board or court of law?:* Have you ever been called upon to answer professional or ethical charges before an Ethics committee or any professional organization, state licensing board or court of law? is Required Yes No If the answer is yes, please give details of the incident leading to an investigation and outcome: If the answer is yes, please give details of the incident leading to an investigation and outcome is not valid Primary Office/Place of Employment:* Primary Office/Place of Employment is Required Business Address (Include Address, City, State, Zip Code):* Business Address (Include Address, City, State, Zip Code) is Required Business Phone Number:* Business Phone Number is Required Business Email Address:* Business Email Address is Required Title of Position:* Title of Position is Required Duties:* Duties is Required I hereby authorize the Membership Chair to contact any person or institution to verify the information above and that the information above is true and correct. I hereby authorize the Membership Chair to contact any person or institution to verify the information above and that the information above is true and correct.: I hereby authorize the Membership Chair to contact any person or institution to verify the information above and that the information above is true and correct. is not valid Yes I agree No I do not agree Please briefly explain the nature of your involvement with the field of psychology (for example, a psychology teacher, psychotherapist, interest in psychology, mental health law):* Please briefly explain the nature of your involvement with the field of psychology (for example, a psychology teacher, psychotherapist, interest in psychology, mental health law) is Required Highest or most relevant degree earned:* Highest or most relevant degree earned is Required Institution or University where currently enrolled:* Institution or University where currently enrolled is Required Type of Degree(s) being pursued:* Type of Degree(s) being pursued is Required Subject Area (s):* Subject Area (s) is Required Date of entry into program (mo. /yr.):* Date of entry into program (mo. /yr.) is Required Anticipated Date of Graduation (mo. /yr.):* Anticipated Date of Graduation (mo. /yr.) is Required Highest Degree Earned to date:* Highest Degree Earned to date is Required Degree Granting Institution:* Degree Granting Institution is Required Do your hold a professional License or certificate? Do your hold a professional License or certificate?:* Do your hold a professional License or certificate? is Required Yes No If yes, what is the type of License/Certificate?:* If yes, what is the type of License/Certificate? is Required Please check the types of student programming you are interested in (to inform our development of student services) Please check the types of student programming you are interested in (to inform our development of student services):* Please check the types of student programming you are interested in (to inform our development of student services) is Required Conferences to showcase student work Mentoring Listserv Networking Public service projects Leadership Opportunities Do you want to be a Mentor to young career psychologists? Do you want to be a Mentor to young career psychologists?:* Do you want to be a Mentor to young career psychologists? is Required Yes No Do you want to be a HSC volunteer therapist? Do you want to be a HSC volunteer therapist?:* Do you want to be a HSC volunteer therapist? is Required Yes No Do you want to be listed on our website directory to receive referrals? Do you want to be listed on our website directory to receive referrals?:* Do you want to be listed on our website directory to receive referrals? is Required Yes No In order for PSCP to know more about you and your practice we are requesting the following information. Please make sure to UNCHECK the boxes of information that DO NOT APPLY to you and your practice. Session Format In order for PSCP to know more about you and your practice we are requesting the following information. Please make sure to UNCHECK the boxes of information that DO NOT APPLY to you and your practice. Session Format: In order for PSCP to know more about you and your practice we are requesting the following information. Please make sure to UNCHECK the boxes of information that DO NOT APPLY to you and your practice. Session Format is not valid I do not see clients/patients Individual Group Couples Family Age Specialties Age Specialties: Age Specialties is not valid I do not see clients/patients Small Child (Under 5) Children Adolescents Adult Older Adults (65+) What is your theoretical orientation? What is your theoretical orientation?: What is your theoretical orientation? is not valid I do not see clients/patients Psychodynamic Cognitive – Behavioral Approaches Mindfulness/Acceptance Based Approaches Integrationist/Eclectic Other Areas of Interest Areas of Interest: Areas of Interest is not valid I do not see clients/patients Addiction ADHD Anger Management Anxiety Disorders Career Counseling Chronic Illness Depressive Disorders Eating Disorders/ Obesity Family/Relationship Issues Grief Infertility LGBTQI Men's Issues Women's Issues OCD Parenting Sports Psychology Trauma Testing and Evaluation Neuropsychological Eval Psychoeducational Eval Forensic/Custody For which are you an in-network provider? For which are you an in-network provider?: For which are you an in-network provider? is not valid I do not see clients/patients Independence Blue Cross/Blue Shield (Keystone, Personal Choice) Highmark Blue Cross/Blue Shield Horizon Blue Cross/Blue Shield Aetna Cigna Optum/ United Behavioral Health Tricare Medicare Medicaid I am not an in network provider for any insurance I accept a sliding fee payment based on income and need I certify that the information given by me in support of this application is true and correct. I certify that the information given by me in support of this application is true and correct. :* I certify that the information given by me in support of this application is true and correct. is Required Yes No Email:* Invalid Email Password:* Invalid Password Password Confirmation:* Password Confirmation Doesn't Match Password Strength Have a coupon? Coupon Code: Invalid Coupon Coupon applied successfully Pay By: Credit Card Pay with your Credit Card via Stripe Checkout JavaScript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it. No val Please fix the errors above davidm2025-12-12T09:04:00-05:00November 12th, 2022| Share This Story, Choose Your Platform! FacebookXRedditLinkedInPinterestVk
