Apply For Membership

Membership Application

First Name

Last Name

Username*

Password*

Confirm Password*

Please make note of your Username and Password. You will need them to log in and complete your profile once your membership is approved.

E-mail Address*

Phone

Website

Primary Office

City / Neighborhood*

Degree and License Designation

Professional License*

Associate Clinical Social Worker (ASW)Associate Marriage & Family Therapist (AMFT)

Associate Professional Clinical Counselor (APCC)Licensed Clinical Social Worker (LCSW)

Licensed Marriage & Family Therapist (LMFT)Licensed Professional Clinical Counselor (LPCC)

PsychologistNone

License Number*

Supervisor Name*

Supervisor License Number*

Certifications and Special Training

Describe your training in Gestalt therapy.*

Only fill in if you are not human