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$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

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? 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? 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? 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? 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. 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? 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) 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? is Required

Yes No

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? 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 is not valid

I do not see clients/patients

Individual

Group

Couples

Family

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? 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 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? 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. is Required

Yes No

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

Password Strength

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