MEMBERSHIP APPLICATIONkuhashmi2021-11-04T14:12:39+00:00 MEMBERSHIP APPLICATIONΔNameEmailAddressCityStateZip CodePhone NumberHighest Educational Level Attained Certificate Bachelor Master Doctorate Associate H.S. DiplomaCredential PhD MD LMHC LCSW LICSW RN APRN LPN MSW MEd MA MSOtherMember Demographic Information In an effort to learn more about our members, we would appreciate your assistance in providing the following information:Gender Female MaleAgeRace/Ethnicity Professional Affiliation (Please check one): Social Worker Mental Health Counselor Community Mental Health Worker Family & Marriage Counselor Psychiatric Nurse Peer Wellness Advocate Traditional/Spiritual Practitioner Psychologist Psychiatrist Religious CounselorOtherProfessional Affiliation (Please check one): Addictions/Substance Misuse Adolescent &Young Adults Aging Care Management & Coordination Children & Families Child Welfare Chronic Medical Illness Complementary and Alternative Behavioral Health Grief/Bereavement Homeless Services Immigrant & Displaced Persons Infant & Early Childhood Mental Health Integrated Behavioral Health Services LGBTQ+ Mental Health Parent-Child Relationships School-Based Behavioral Health Virtual Behavioral Health CareMembership Category (Please check one) Behavioral Health Providers Collaborative Haitian Behavioral Health Providers CollaborativeAnnual DuesAnnual Dues Student = $25 Para-Professional = $40 Regular Membership = $120Pay with PayPal
