Membership Application for the Fresno Area Psychological Association (FAPA)


	New Member Application Complete this form to join FAPA

Add Your New Membership Profile

First Name
Last Name
Degree
License Number
Phone
Fax
Email

Company/Organization
Address
City State Zip
Home Address
City State Zip
Home Phone
	Make my email available online DO NOT make my email available online
Create Login Password

Theoretical Orientation

Behavioral	Cognitive/Behavioral	Family Systems	Feminist
Gestalt	Humanistic/Existential	Psychodynamic	Solution Focused
Eclectic
Other (please specify)

Treatment Modalities

	Child	Adolescent	Adult	Older Adult
Individual Psychotherapy
Group Therapy
Psychological Testing
Neurological Testing
Check those that apply
Marital therapy	Biofeedback/Relaxation Training
Family therapy	Clinical Evaluation
Play Therapy

Practice Settings

Managed Care (Which one?)
	Child	Adolescent	Adult	Older Adult
Hospital Practice
Government agency
University or school setting
Correctional System Military Police/Law Enforcement
Private Practice Sliding Scale? Evening Hours? Weekend Hours?
Other (please specify)

Areas of Interest

From the list below, check up to six activities that best describe your focus:

Adolescents	Custody evaluations	Managed Care	Religious Issues
Adoption Issues	Depression	Management	School Psych
Clinical Psychology	Developmental Disabled	Media	Seniors
AIDS/HIV	Developmental Psych	Men's Issues	Separation
Anger Management	Disaster Psychology	Military Issues	Sex Offenders
Anxiety Disorders	Dissociative Disorders	Mood Disorders	Sexual Abuse
Attention Deficit	Divorce Mediation	Neuropsychology	Sexual Harassment
Biofeedback	Domestic Violence	Obsessive-Compulsive	Sexual Therapy
Grief	Eating Disorders	Organic Disorders	Sleep disorders
Career Counseling	Emp. Assistance Prog.	Personality Disorders	Somatoform Disorders
Child Abuse	Ethnic/Cultural Issues	Phobias	Sport Psych
Children	Families	Pain Management	Stalking
Chronic Mental Illness	Forensics	Physical Abuse	Stress Management
Clinical Hypnosis	Gay/Lesbian Issues	Physically Disabled	Substance Abuse
Learning Disabilities	Health Psychology	PTSD/Trauma	Supervision
	Reproductive Issues	Psychological assessment	Teaching
Community Organization	Hypnosis	Psychopharmacology	Technology
Counseling Psychology	Humanistic/Existential	Psychosis	Victims of crime
Couples Impulse Disorders	Industrial/Organizational	Public Agency	Women's issues
Criminal Justice System	Cults	Rehabilitation	Worker's compensation
Crisis Intervention	Jungian Analysis	Relationships	Workplace Violence
Education (what topic)
Research (what topic)
Other (please specify)

Other Associations
you belogn to

I wish to join FAPA for the current calendar year. Please select the appropriate member category.
Full Member (Doctorate in Psychology, BOP Licensed,or Diplomat) Please specify	Dues $80
Full Member First Year Graduates (Doctorate in Psychology)	Dues Free for First year
Student Member (currently enrolled in a full time psychology training program) (students will be listed in the student section)	Dues $20
Retired Member of FAPA (retired)	Dues $40
Emeritus Member (retired and a minimum of ten years involvement with FAPA/SJPA. This category is awarded by the executive Board of Directors. Please call the membership chair for consideration.)	Dues NONE

Although November 15th is the cut-off date for inclusion in the yearly printed directory,
your membership WILL BE listed in the FAPA web site membership search engine.

Do you have a current professional will?

Please check one option:
      YES
      NO
      I don't need a professional will because I have no independent
           responsibility for client care or client records (current or past).

For anyone who has indicated that they have a current professional will, you will be entered into a drawing for a FREE 2006 FAPA Membership. You must however, get your application in by the deadline to be eligible for the drawing.

If you do have a will and would like FAPA to keep a record of the name of your Professional Executor, please list their contact information below. In the event of your death or incapacitation, FAPA could then direct inquiries to your contact person. FAPA can't assume any responsibilities for the records or clients but we can provide contact information to the community.

Name
Address
Phone

Payment Information

Dues
Payment Method
	Credit Card
	Will Mail a Check
	I'm qualified for a FREE membership this year
Credit Card		Use: Visa, MasterCard or American Express
Name on Card
Card Number / Expiration
Security Code (3 digits on back)

I understand that my submitted information, except for my home address, home phone, and credit card information (of course), will be publically available on the FAPA web site. My submission of this online form is my electronic signature indicating that I have read and understand this fact.

. . . Thank you!