APPLICATION
FOR MEMBERSHIP
Please print or type all information.
You may attach additional pages as needed.
Membership Chair: Kristin Staroba, MSW
301-951-3939 kstaroba@juno.com
Type of
membership (see minimum requirements under
“Membership” on our website, www.aapweb.com)
Please check one:
□ full member
□ associate member □
post-graduate associate □ student
affiliate
GENERAL INFORMATION
Name_______________________________________
DOB____sex__
Email
address_____________________________________________
Business
address___________________________________________
City/state/zip_________________________________phone________
Home
address_____________________________________________
City/state/zip_________________________________phone________
· Total years of post-graduate clinical experience________
· discipline____________________
· license/state*_____________________license
#________________
(*Note: If the governmental jurisdiction in which you practice does not require licensing or certification for the independent practice of psychotherapy, please contact the Membership Chair before submitting application.)
· If an academy member is recommending you, who is
it?_________
· How did you hear about
AAP?______________________________
· Have you previously applied for membership? Y/N
(If yes, explain on separate sheet.)
· Are you an associate member, post-graduate
affiliate, or student affiliate?
Y/N If so, when did you join and
who is your academy mentor?_______________________ (If you are an associate
member, complete only relevant sections documenting hours.)
EDUCATION
(UNDERGRADUATE, GRADUATE)
Institution/city dates
attended major field degree
__________________ _____________ ____________ ______
__________________ _____________ ____________ ______
__________________ _____________ ____________ ______
__________________ _____________ ____________ ______
INTERNSHIPS, RESIDENCIES, TRAINEESHIPS, ETC.
_______________________ ______ ________________
_______________________ ______ ________________
_______________________ ______ ________________
_______________________ ______ ________________
__________________________ ________ ____ ____________
__________________________ ________ ____ ____________
__________________________ ________ ____ ____________
__________________________ ________ ____ ____________
__________________________ ________ ____ ____________
PSYCHOTHERAPY SUPERVISION
Please list supervisors chronologically and
include COMPLETE current address. If supervisor is deceased or genuinely cannot
be located, please provide an alternative way for us to confirm your hours.
Name/degree___________________________dates______________
Address__________________________________________________city/state/zip______________________________________________
Theoretic
orientation_________________________AAP member? Y/N
Total
hours spent in: individual supervision___ group supervision____
Name/degree___________________________dates______________
Address__________________________________________________city/state/zip______________________________________________
Theoretic
orientation_________________________AAP member? Y/N
Total
hours spent in: individual supervision___ group supervision____
Name/degree___________________________dates______________
Address__________________________________________________city/state/zip______________________________________________
Theoretic
orientation_________________________AAP member? Y/N
Total
hours spent in: individual supervision___ group supervision____
PERSONAL PSYCHOTHERAPY
Please list therapists chronologically and
include COMPLETE current address. If therapist is deceased or genuinely cannot
be located, please provide an alternative way for us to confirm your hours.
Name/degree___________________________dates______________
Address__________________________________________________city/state/zip______________________________________________
Theoretic
orientation_________________________AAP member? Y/N
Total
hours spent in: individual therapy___ group therapy____
(Personal
Psychotherapy list continues next page ….)
(Personal
Psychotherapy, continued from previous page.)
Name/degree___________________________dates______________
Address__________________________________________________city/state/zip______________________________________________
Theoretic
orientation_________________________AAP member? Y/N
Total
hours spent in: individual therapy___ group therapy____
Name/degree___________________________dates______________
Address__________________________________________________city/state/zip______________________________________________
Theoretic
orientation_________________________AAP member? Y/N
Total
hours spent in: individual therapy___ group therapy____
PROFESSIONAL REFERENCES
Please list the names and complete addresses of
three additional people who know your professional work, and note if they are
AAP members.
Name_____________________________________AAP
member? Y/N
Address/city/state/zip_______________________________________
Name_____________________________________AAP
member? Y/N
Address/city/state/zip_______________________________________
Name_____________________________________AAP
member? Y/N
Address/city/state/zip_______________________________________
· Other current professional affiliations (please
spell out organizations’ full names):
________________________________________________________________________________________________________________
________________________________________________________
Has your license to
practice ever been limited, restricted, suspended, voluntarily surrendered,
revoked, or not renewed? Y/N
Have you ever been
reprimanded by a state licensing agency? Y/N
Are there any actions
pending with respect to your license? Y/N
Are you under
investigation by any licensing or regulatory agency? Y/N
If you answer “Yes” to any
of these questions, please explain below:
Please mail
this completed application to the Membership Chair with:
q a nonrefundable application fee of $50--check
payable to the
q a photocopy of your current professional license;
q an official copy of your graduate school transcript
showing completion of degree (you may have your institution mail directly to
Membership Chair);
q other pertinent information you wish to include.
We suggest
keeping a copy for yourself.
By signing and submitting
this application, I assert that all the information provided is true to the
best of my knowledge. I hereby give permission to all supervisors, therapists,
and references listed to release confidential information about me
(specifically hours spent in therapy and supervision). I give the Membership
Chair permission to contact all of these references and understand that their
responses will be reviewed only by AAP members serving on the academy’s
Membership Committee and Executive Committee and Council.
______________________________ _______________________
printed full name and
degree signature
______________
date
Thank you for applying to the
Kristin Staroba
Membership Chair
AAP Membership Application,
revised 4/11/07