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
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