*NOTE: Fields in Bold are Required
Membership Type:
$100.00
$50.00
$50.00
$35.00
If you are a student,
If you are a student,
Home Address:
Home City:
Home State:
Home Zip:
Home Phone Number:
(xxx) xxx-xxxx
Company Name:
Business Address:
Business City:
Business State:
Business Zip:
Business County:
Business Phone Number:
(xxx) xxx-xxxx
Business Fax Number:
(xxx) xxx-xxxx
Primary Email Address:
Secondary Email Address:
Birthdate:
Marital Status:
Practice Opening Date:
Degrees:
Training and Credentials:
Type of License or (enter N/A if not applicable)
(LMHC, LMFT, LMSW, etc.)
State of License: (choose N/A if not applicable)
Would you like a Membership Certificate suitable for framing? The cost is an additional $20:
Please print your name exactly as you would like for it to appear on your Membership Certificate:
Check any Committees
Any other activities or expertise you would like to contribute to NYMHCA:
Would you like information regarding becoming a participant in our Speaker's Bureau?: (Speakers Bureau materials will
be sent to you by mail with membership material)
Donation to ongoing Legislative Efforts:
Please choose a
How did you learn about
If you would like us to send
The Find A Clinical
This directory is for those looking for a Supervisor. This service is $35 per year or $65 per year if you also select the Expanded Listing on the Find A Counselor Directory.
Would you like to be listed as a Clinical Supervisor?:
Educational Affiliation:
Average Charge Per
Please write a brief statement about your Philosophy of Clinical Supervision:
The Find A Counselor Directory
A Basic Listing is free - and part of your NYMHCA membership. An Expanded Listing will tell potential clients more about you and the services that you offer, including listing your web site address or email address if you desire. An Expanded Listing is only $35 per year (or $65 per year with the Find A Supervisor listing).
Would you like to be listed on the Find-A-Counselor Directory?:
If you choose "YES", your contact information will be accessible to visitors who are looking for a therapist on the NYMHCA.org web site. If you choose "NO", then none of your information will be accessible to visitors who may be looking for a therapist .
If you chose "YES" to be listed on the Find-A-Counselor directory, choose a type of listing:
Specialties:
Other Associations Memberships:
Find-A-Counselor Directory Expanded Listing Information
This is for all Expanded Listings. You need only to complete this if you are purchasing the expanded listings.
You do NOT need to complete this section if you are not listed on the Find A Counselor Directory or you have a Basic - Free Listing on the Find A Counselor Directory.
Second Office Address:
Second Office City:
Second Office State:
Second Office ZIP:
Second Office Phone Number
How to schedule an appointment:
Email Address:
only one address
(If you do not want your email address listed in the Find A Counselor Directory,
Your Web Page Address:
http://
Education: (graduate and post graduate)
Your Gender:
Type of Therapy conducted:
Philosophy -
Years in Practice:
Do you have any special insights for clients of the following ethnicities:
Other Ethnic Insights:
Please list all languages spoken fluently:
Average Charge Per Session:
Type of Payment Accepted:
Insurance accepted:
Type of Insurance accepted:
Print this form. Please make checks payable to NYMHCA. Mail both the registration form and payment to:
NYMHCA
