Member Benefits Become a Member Renew Your Membership			New Member Application Form To become a member of NCSPP, simply complete the following form and click "Submit." You will then be taken to a screen where you can make an instant payment online. If you would prefer to mail a check please print an application and mail with your payment to NCSPP / 12 Hampton Avenue / San Anselmo / CA / 94960. Member Information First Name, Last Name, Degree (e.g., Joan Smith, Ph.D.) License Type/Number/State Email and Web Public (whether this information will be shared with other NCSPP Members? SELECT ONE Yes No Email Address Alternate Email Address Website Address Office 1 (Mailing Address) Public (whether this information will be shared with other NCSPP Members? SELECT ONE Yes No Address (Please include City, State and Zip Code) Phone Number: Fax Number: Mobile Number: Office 2 Public (whether this information will be shared with other NCSPP Members? SELECT ONE Yes No Address (Please include City, State and Zip Code) Phone Number: Fax Number: Mobile Number: Personal Address Public (whether this information will be shared with other NCSPP Members? SELECT ONE Yes No Address (Please include City, State and Zip Code) Phone Number: Fax Number: Mobile Number: Professional Information Public (whether this information will be shared with other NCSPP Members? SELECT ONE Yes No Specialties APA Member SELECT ONE Yes No Division 39 Member SELECT ONE Yes No Year Became Licensed Graduate School and/or Other Affiliations How You Heard About NCSPP Membership Level Full member ($105): All licensed mental health professionals who have an interest in psychoanalysis and/or psychoanalytic psychotherapy. Member status does not, by itself, imply competence to practice psychoanalysis and/or psychotherapy. Associate Member ($50): Individuals, not currently students, who are not licensed in any of the mental health disciplines, or who are no longer practicing in any of the mental health disciplines, or who live out of state (and thus are unable to take advantage of our programs in person). Student ($25): Individuals currently enrolled in an undergraduate or graduate school in a mental health discipline. MUST FAX (415.457.6276) or EMAIL A COPY OF CURRENT STUDENT ID TO COMPLETE APPLICATION PROCESS. SELECT ONE Full Member ($105) Associate Member ($50) Student ($25) - must fax/email copy of student id
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