Online Application | American Academy of Psychotherapists

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Name

This field is for validation purposes and should be left unchanged.

Membership Type

There are three (3) types of membership: Full, Associate and Student Affliate. Choose one.

There are three (3) types of membership: Full, Associate and Student Affliate.*

Full Member

* Has a doctoral or professional degree in psychiatry, clinical or counseling psychology, social work, pastoral counseling, marriage and family therapy, counseling or nursing
* Meets requirements for relevant licensure or certification authorizing independent practice of psychotherapy
* Has specific training in psychotherapy
* Has had at least 100 hours of individual clinical supervision; (validated by state licensing board with a 100 hour supervision requirement, otherwise verified by previous supervisors)
* Has had at least 100 hours of individual psychotherapy
* Has at least one year of post-graduate clinical experience if doctoral level, two years for others (or the equivalent in part-time experience)
* 5 References

Associate Member

* Does not meet the requirements for Full Membership
* Has completed a relevant professional degree
* Is currently practicing psychotherapy under supervision as is appropriate to the pursuit of licensure
* Has recommendations from at least three faculty members, supervisors, and/or Academy members
* Has completed or is actively engaged in obtaining 100 hours of personal psychotherapy
* Agrees to work with an Academy member mentor
* May be an associate for no more than seven years
* 3 References

Student Affiliate

* Is currently enrolled in a relevant graduate degree program
* Has recommendations from at least two faculty members, supervisors and/or Academy members
* Agrees to work with an Academy member mentor.
* 2 References, one of these may be a faculty member

General Information

Name of Applicant*

First Last

Email*

Date of Birth*

Business Address*

Business City, Street, Zip*

Business Phone*

Home Address*

Home City, Street, Zip*

Home/Alt Phone*

Total years of post-graduate clinical experience*

Discipline

Type of License / State / License Number*

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 the application.

Name of Academy member recommending you:

(if applicable)

How did you hear about AAP?

Check all that apply.

Attended a Salon

Attended an Institute & Conference

Personal recommendation

Professional journal, Voices

Other

Other - How'd you hear

Have you previously applied for membership?

Yes

previously applied yes, explanation

Please explain:

Are you an Associate Member or Student Affiliate?

Yes

Associate Member or Student Affiliate?

When did you join and who is your mentor?
(If you are an associate member, complete only relevant sections documenting hours.)

Education

Use the + button to add additional rows as needed.

Graduate, Undergraduate*

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Institution

Degree

Major Field

Dates Attended

Internships, Residencies, Traineeships, Etc.*

Add another row with the + button

Institution/Agency

Type of Work

Dates

Paid Experience to Date*

Add another row with the + button

Institution/Agency/Practice

Dates

Hours/week

Personal Psychotherapy*

Please list therapists in chronological order. If your therapist cannot be located or is deceased, please provide an alternative way for us to confirm your hours. If you do not have information to fill in all the blanks, please use xxx to complete the form.
Add another row with the + button

Name of Therapist

Degree / License Type

Dates

Hours in Individual Therapy

Hours in Group Therapy

References

Please provide demographic information for each reference you are requesting.

* You are responsible for selecting your own references, confirming that they agree to be a reference and directing them to this form on the website.
After the reference is filled out they will be asked to send an email to the Membership Chair authenticating their submission. As noted on the form, references must include their discipline/degree.

* A minimum of five (5) references are required:
1. Your therapist(s) must confirm that you have had at least 100 hours of personal psychotherapy.
2. You may have one letter of reference from a supervisor/s
3. You may have one letter of reference from a colleague/s
4. You may have one or more from AAP members themselves.

PLEASE SUBMIT YOUR APPLICATION FOR MEMBERSHIP PRIOR TO REQUESTING YOUR REFERECES.

*STUDENTS: Only two (2) references are required; one of these may be a faculty member.

*Have your graduate institution send or email a transcript or proof of graduation directly to the AAP Membership Chair (address top of page).

If any of the above therapists are deceased or cannot be located please contact the membership chairperson to choose an alternate way to document your hours.

Reference #1*

Name & Degree

City, State Zip

Reference #2*

Name & Degree

City, State Zip

Reference #3*

Name & Degree

City, State Zip

Reference #4*

Name & Degree

City, State Zip

Reference #5*

Name & Degree

City, State Zip

Disclosures

Has your license to practice ever been limited, restricted, suspended, voluntarily surrendered, revoked or not renewed?*

Yes

disclosure explanation

Please explain:

Have you ever been reprimanded by a state licensing agency?*

Yes

reprimanded by state explanation

Please explain:

Are there any actions pending with respect to your license?*

Yes

Actions pending explanation

Please explain:

Are you under investigation by any licensing or regulatory agency?*

Yes

under investigation explanation

Please explain:

Has there been any report in your name registered with the Professional Environment Policy Committee and/or the Ethics Committee?*

Yes

PEP or Ethics explanation

If so, what were the recommendations and have they been responded to and/or resolved?

AAP is a small community of therapists. With that in mind, are you aware of any dual relationships that may provide challenges for you or a current member?*

Yes

Have there been attempts between you and the other party to work through how these challenges will be handled if you become a member?*

Yes

Copy of your current professional license:

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

Signature*

By signing and submitting this application, I assert that all the information provided is true to the best of my knowledge. Typing my full name in the box below serves as my signature for this application. I hereby give permission to all supervisors, therapists and references listed to release the specific hours spent in therapy. I give the Membership Chair permission to contact all references. Their responses will be reviewed only by the Membership Committee and the Executive Council as my application is presented for membership in the Academy. All membership applications are subject to the review and approval of the Executive Council of AAP.

Product Name

Application Fee

This is non-refundable

Credit/Debit Card*

Card Details

Cardholder Name