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Santa Barbara County Psychological Association

 Membership Application Form
Copy and Mail with check and Referral to:
P. O. Box 24018, Santa Barbara, CA 93121

SBCPA Member Application Form

SBCPA Membership:__New__Renew__Updating info  
CA  License PSY#________ LEP#_______  Other_____________                                                     

Last                     
Name:___________________MI:__ First:_________ CPA Member?__Y__N                                      

Degree:__PhD __PsyD __EdD __LCSW __MFT __Other            
Student: __School __Internship:                                 

 
Site #1**  I would like SBCPA to publish Site #1 information __Y __N 
(if No, info will not be on website or in Membership Directory)

__Home   __Practice      __Agency /Program  Name:                                                                           

Street:                                                                                                   City:                                                        CA    Zip

Email:                                                                                                    Website:

Phone:                                                                                                   FAX:


Site #2**   I would like SBCPA to publish Site #2 information __Y __N 
(if No, info will not be on website or in Membership Directory)

__Home   __Practice      __Agency /Program    

Name:                 

Street:                                                                                                    City:                                                        CA    Zip

Phone:                                                                                        Email:                                                                                                                                                                            
I am interested in helping out in the following areas:

 

__Membership/ Events

__Continuing Ed

__Ethics   

__Diversity

__Government Affairs

__Website / Newsletter

Practice / Agency Profile

Clientele served:
Adolescents ___
Adults ___
Children ___
Couples __
Families ___
Groups ___
Seniors ___
Other___________________ 		Services Provided :
Consultation ___
Educational Assessment ___
Forensics & Legal Consults ___
Neuropsychology ___
Evaluation ___
Psychotherapy ___
Other___________________

Specialties:
Anxiety ___
Behavioral ___
Business consultation ___
Depression ___
Developmental problems ___
Eating disorders ___
Hypnosis ___
Learning disabilites and AD/HD
Life transitions and personal growth ___
Physical illness ___
Relationship problems ___
Research ___
Serious mental illness ___
Substance Abuse ___
Trauma ___
Women's issues ___
Other____________________

Language:
Spanish ___
Other_________________

Orientation:
Cognitive ___
Cognitive-Behavioral ___
Developmental ___
Existential ___
Family Systems ___
Feminist ___
Focusing-Oriented ___
Gestalt
Jungian ___
Psychoanalytic & Psychodynamic___
Rogerian___
Spiritual ___
Other____________________

** You may also compose a description of you and/or your practice or agency that will appear on your individual page at the SBCPA website.  You are encouraged to send include a photograph. We will need for you to submit this information through email. Please indicate here that you have material to submit and we will contact you to arrange your submission. _____Yes

Type of Membership

Fee

 

 Full

$80.00

 

 Students

$20.00

You signature verifies the accuracy of the information you have provided.

Signature________________________________ 

Date___________________                                   

Mail your completed Member Application and check to

SBCPA at:   P. O. Box 24018, Santa Barbara, CA 93121.