American Psychotherapy Association New Membership Application

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Why join?

The American Psychotherapy Association provides credentialing, standards of practice, professional identity, and self-regulation for the psychotherapy profession. As a member of the American Psychotherapy Association you receive exclusive benefits and services to help you and your patients including:

Opportunities to increase patient referrals through our exclusive, online directory
Networking opportunities
Free online, self-paced continuing education
Subscription to the official American Psychotherapy Association journal
Discounted rates on certifications and other continuing education opportunities
Exclusive low-cost insurance rates

Join now.

For more information, please call:

1.800.205.9165

Please complete the application below to apply for American Psychotherapy Association membership. All submitted applications are reviewed and verified.

You may also download this application to send in by fax or mail.

After submitting this application, you must forward a copy of your current résumé/vitaé, a copy of your professional license(s), and a copy of any supporting documentation by fax or mail to American Psychotherapy Association. Please refer to the confirmation page after this application for fax and mail information.

Enter Your Profile Information - Red fields are required

Prefix/Title: (e.g. Dr., Mr., Ms., etc.)

Full Name:

Designation(s):

Suffix: (e.g. Jr., Sr., III, etc.)

Occupation:

Exact Job Title:

Address Line 1:

Address Line 2:

City:

State/Province:

Postal Code:

Office Phone Number:

Country:

Home Phone Number:

Fax Number:

Website:

E-mail Address:

Date of Birth :

How did you hear about American Psychotherapy Association?

If referral, publication, or other, please specify:

Type your name as you would like it to appear on your certificate and include designations if needed; designations must have documentation on file before being added.

Highest Degree Earned:

Select description of your practice:

Group Private Agency

Other

American Psychotherapy Association Membership

Please select the appropriate membership category.

	Standard
	Standard Memberships are for 1-Year and are paid in full, immediatly withdrawn from your account.
	$65	Student Member (must be enrolled 9 credit hours and submit proof of student status, per year - undergraduate degree programs only)
	$165	Standard Membership (per year)
	$190	International Membership (+$25 for postage, per year)
	Automatically renew my membership every year.
	Lifetime
	Lifetime Memberships can either be paid in full, immediatly withdrawn from your account, or by setting up a payment plan. Payment plans are withdrawn from your account on the first of every month. (never pay dues again)
	$2500	Life Membership

If you are licensed, please provide your license number and submit a copy of your license via fax or mail to American Psychotherapy Association.

License #:

State:

List two professional references. (Required)

Name:	Phone #:
Name:	Phone #:

If you have a reference code, please enter it below.

Reference Code:

If you have a discount code, enter it here:

Note: If you do not have a discount code, please enter: NA.
Need help locating the code?

Payment Information

Payment plans are available for Life Memberships. A minimum down payment of $150 (non-refundable) must be made with this application and a minimum monthly payment of $100 must be made. Your certificate will be issued upon full payment.

If you do not wish to use the payment plan, then disregard the down payment and monthly payment fields and leave them blank.

Down Payment:
$ .00

Monthly Payment:
$ .00

*Payment Type:
*Credit Card Number: no dashes or spaces	*Expiration Date: /

Terms of Agreement

I certify that the information I have provided to American Psychotherapy Association^® is true, correct, and complete. I am not providing misleading, false, or deceptive information. I understand that if I have provided misleading, false, or deceptive information, the association will pursue aggressive legal action. I may be asked to provide additional documentation. I understand that American Psychotherapy Association reserves the right to verify any and all information that I provide. If I misrepresent my credentials, refuse to provide documentation at a later time if asked, or allow my membership with American Psychotherapy Association to lapse, I understand and agree that my membership and/or certification status will be revoked and my membership terminated. If the documentation required for the credential or membership status for which I am applying is not received within 6 months from the date of application, I understand that no refund will be issued in the event of the cancelation or denial of my application. I agree that I will notify American Psychotherapy Association in writing of any civil, criminal, or complaint that is made against me. I agree to hold harmless and indemnify American Psychotherapy Association and its officers, directors, employees, and agents for any misrepresentation of my credentials and for all claims, loss, judgment, or expense. American Psychotherapy Association does not endorse, guarantee, or warrant the work or opinions of any individual members. Membership does not imply licensing or registration by the organization of a member's qualifications, abilities, or expertise. The objective of American Psychotherapy Association's publications and the activities that it sponsors are for informative and educational purposes. The views expressed by the authors, publishers, or presenters are their own views and do not necessarily reflect those of American Psychotherapy Association. American Psychotherapy Association does not assume any responsibility or liability for its members or subscribers' efforts to apply or use the information, suggestions, or recommendations made by the organization, publication resources, or activities. There is a $75 administrative fee deducted for all cancelled and/or denied applications.

I certify that I have read the above statement and agree to all of its terms

Yes No

Have you ever been convicted of a felony?*

If yes, please explain.

Yes No

Have you ever been disciplined, or are you currently under investigation, by any legal or licensing board? *

If yes, please explain.

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American Psychotherapy Association
2750 E. Sunshine St.
Springfield, MO 65804
(800) 205-9165
(417) 823-9959 fax
Hours
Mon-Fri 8-5pm CST
info@americanpsychotherapy.com