Professional Membership Application

Your membership includes a full page listing on our website and in our treatment directory. Please complete the following application to be included in the online directory. Thank you!

Referral Listing (Name and Contact Info EXACTLY as you would like it to appear on our website and in print):

* Your preferred full name as it should appear in the public directory (*required)

Professional Credentials (*required)

Name of practice (*required)

Job Title (*required):

Business/Organization (*required)

Your primary Address (*required)

City (*required)

State (*required)

Zipcode (*required)

Phone number to be displayed in the public directory (*required)

Fax number to be displayed in the public directory (*required)

Your Email (*required)

Do you want your email included with your listing on our site? (*required)

Website URL (http://www.namehere.com)

Mailing Address if different from above

TREATMENT DETAILS:

Treatment Setting (check all that apply)

Select any of the following populations served (check all that apply):

Treatment Offered (check all that apply):

Certification(s): Initials (without periods) of community recognized credentialing organizations (NCC, LCSW) and/or spelled-out names (Emotionally Focused Therapy trainer)

Specialization(s): Special populations served and/or specific issues such as trauma, sexual abuse, addiction, divorce/separation, relationship issues, mood disorders, eating disorders, postpartum depression, etc.

Practice description (50 words maximum): * Please compose a 50-word description of your practice in the third person. You can provide your philosophy or approach to your specialty area. You can highlight special features of your practice or your setting. You can state if you will offer a discount or other special consideration to patients who find you through A Place Of Healing. You can give details about your background and training.

Other memberships: In order for us to coordinate efforts with other professional organizations, please indicate your memberships in other local professional associations (if any).

Credentials/Licensing of your practice and/or facility: (Ex: JCAHO/Joint Commission, state licensing and others)

Additional services and characteristics: (Check all that apply)

I am a licensed therapist, and I would like to be contacted about becoming a support group facilitator for A Place Of Healing

Please list any suggestions for improving our service or this form. Also, do you know any professionals who would like to be contacted about membership?

I agree that all the information is true and correct to the best of my knowledge. AND I agree to the following...

I understand that my membership with A Place Of Healing is dependent upon my continued status with my certification and or licensing bodies. I agree that if my state board license/registration/certification is revoked, suspended or expired, I will contact A Place Of Healing and provide written documentation as to the reasons. *