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Join or Renew Your Membership Today

 

 

 

2017-2018  DUES STATEMENT

 

Dr.  Mrs.  Ms. Mr.
First Name: Last Name:

Address: Zip:

Please check if this is a new address
Highest Degree              

2017-2018 Dues ($90.00)
Life Member  ($40.00)
Associate Member ($60.00)                                 
Student Affiliate (Free exemption)         
Referral Service* ($30.00)                                     
Speakers Bureau [fill in information below] ($ 5.00)
Test Kit Library ($70 new members; $50 old members without a lapse)
Contribution to WCPE                                     
Contribution (General Fund-WCPA)
Late Fee  (after 6/15/17)       $10.00    
                                                                      

Total:                        

Pay with PAYPAL on our website or make checks payable to WCPA and return to PO Box 339-H, Scarsdale, New York 10583

Please check the division(s) you wish to join (even if previously responded; there is no separate fee for joining a division)
Academic          Clinical        School         Division of Gender & Cultural Issues

PLEASE PRINT  YOUR E-MAIL ADRESS HERE:

 * * * * * * * * * * * * * *

REFERRAL SERVICE

* If you have previously been a member of the Referral Service and have no changes to your listing check here .

If you are new to the referral service or have changes to your current listing, please complete this form in its entirety.

Please include the $30.00 fee for the referral service along with your dues payment.

A copy of your malpractice insurance and NYS registration is required. 

IF YOU DO NOT WISH TO BE LISTED ON THE WEBSITE CLINICIAN DATABASE AND ONLY IN THE WCPA OFFICE

Name:         License #

Office address(es) in Westchester (maximum of two):

Address 1:

Address 2:

Tel. #: E-mail:

Services:  

Psychotherapy                                   Testing
Children                                          Children 
Adolescents                                       Adolescents 
Adults                                                     Adults 
Family                                                                 Vocational           
Group    Ages
                 Educational         
Couples/Marital                                                    Neurospsych        
Cognitive Behavioral

Other (specify):

Do you accept Medicaid?   Medicare?

Are you a provider for any managed care organizations? Yes No
If yes, which one(s) [it is important to name them and let WCPA know if you join or drop any carriers during the year]



List the languages (other than English) that you are fluent in:



Will you accept a low fee patient? Yes No @ what fee
NYS Reg Exp:   Ins Exp:

DON’T FORGET TO INCLUDE COPIES OF NYS REGISTRATION CERTIFICATE & INSURANCE FACESHEET IF YOU ARE JOINING THE REFERRAL SERVICE.  PLEASE REMEMBER TO KEEP WCPA INFORMED OF ANY CHANGES

 * * * * * * * * * * * * * *

SPEAKERS’ BUREAU

Please complete this section if you wish to participate in the Speaker's Bureau.

Name:        Degree:

Address:

City:      State:     Zip Code:

Telephone #:                          

E-mail Address:

Current Position:

TOPICS/TITLES OF TALKS:


BRIEF BIOGRAPHY



Would you be willing to provide talks on a pro bono basis ? Yes         No

I agree to require each group or sponsoring organization to acknowledge that the expression of my views as a speaker, if selected through the Speakers’ Bureau, do not necessarily represent the view of the Westchester County Psychological Association, and that my views as a speaker are the expression of my personal views only.

 

Date: Signature: