Professional Development Program Membership Application Form
Name:
Office Address:
City:
State /Zip:
Email:
Office Telephone:
Degree:
License Type:
License #:
Brief description of professional activity/affiliations/interests in psychotherapy for roster listing (20 words or less):
Do you want the above information listed in our Annual Membership Roster (Must be received by September 15)? Yes: No:
September-August Membership Fees:
$50 Regular Membership (Licensed Mental Health Professional) $30 Associate Membership (Unlicensed)
I am interested in learning more about CIP's committees:
Professional Development Program Committee (generates and organizes the Seminars for Professionals and the Advanced Clinical Case Conferences; works with one Core Staff Member)
Community Education Program Committee (generates and organizes educational materials and presentations for the community)
Communications Committee (works on public relations, graphics, etc.)
Event Planning Committee (helps with Annual Gala [participating on the Sponsor, Auction, or Food/Beverage Committees], Share Your Healing Story, and/or other events)
Development Committee (helps with fundraising)
Community Notes Newsletter Committee (writes and/or solicits one article for each quarterly issue)
Alumni Committee (organizes alumni events, requests information for "Alumni Notes" in quarterly newsletter)
I can't make a commitment, but I'd like to help when I can. Please call me if there's a need.
For more information, phone (415) 459-5999 x101
Map and Directions CIP Brochure CIP Newsletters Contact CIP
Board of Directors Administrative Staff Clinical Staff Advisory Committee
Hours and Facilities Making an Appointment On-Site Programs Off-Site Programs Conditions Treated Client Profiles
Relationships Families Parenting Helping Kids Succeed Diversity/Tolerance Depression Anxiety Grief Anger Trauma Abuse Addiction Eating Disorders Start Intuitive Eating Bipolar Disorder Checklists for Health Emotional Screening Day Community Conference Tips to Handle Holiday Stress
Not Used...
Seminars for Professionals Study Groups & Classes Supervisor Training Program CIP Brochure
Register for a Class or Seminar
Professional Membership Join Now
CIP Internship Opportunities Current CIP Internships Sample Training Topics
Ticket to Ride - Success! Get Involved!
2010 Sponsors Organization Overview
Personnel Directory Map and Directions Hours and Facilities Making an Appointment
4 Reasons to Help Dollars and Sense Become a Donor Business Partnership Join our Board Advisory Committee Education Committee Communications Committee Supervise or Train Interns Sponsor Committee Event Planning Committee Auction Committee Donate Auction Items
