Membership Application

* = Required Fields
Membership Information
First Name:*
Middle Initial:
Last Name:*
Email:*
Institutional Affiliation:
 
Primary Address
Address:*
Suite:
City:*
State/Province:*
Zip/Postal Code:*
Province:
(If not listed above)
Country:*
Business Phone:
Business Fax:
I would like my Primary Address to be included in the online therapist referral search. Only name, degree, city, state, and office phone will be provided. I understand that by checking this box, I agree that my name will be available in an online public search.
Absolutely do not list me in the membership directory at all.
I would like only a partial listing in the membership directory (includes name/city/country).
 
Mailing Address
(where you would like Society information sent)
if mailing address and primary address is the same
Address:
Suite:
City:
State/Province:
Zip/Postal Code:
Province:
(If not listed above)
Country:*
Alternate Phone:
 
Other Information
My Mailing Address is : Home      Office
Credentials: LCSW      PhD      MD      MFT      Psy.D      MEd      Other:
License #:
 
Professional Discipline or Specialty
 
Education Medicine
Nursing Other
Psychology Psychotherapy
Psychiatry Social Work
 
Special Interests
 
Adolescence Adulthood
Criminal Abuse Child Dissoc
Childhood Consulting
Education EMDR
Forensic Hypnosis
MFT Research
Ritual Abuse
 
International Society for the Study of Trauma and Dissociation    8400 Westpark Drive, Second Floor, McLean, VA 22102
Telephone: 703/610-9037    Fax: 703/610-0234    E-mail: info@isst-d.org    Copyright © 2004-2008 by ISSTD