by Marla.lardiere | May 7, 2020 Price: Free First Name:* First Name Required Last Name:* Last Name Required Prefix: Prefix is not valid E-mail:* E-mail is Required Primary Phone:* Primary Phone is Required Cell: Cell is not valid Fax: Fax is not valid Gender:* Gender is Required Female Male Transgender Other Birth Date:* Birth Date is Required Ethnicity (optional): Ethnicity (optional) is not valid ----------African/BlackAlaskan Native/Native AmericanAsianHawaiian Native/Pacific IslanderHispanic/LatinoEuropean American/CaucasianOther If Other please specify: If Other please specify is not valid Home Address: Home Address is not valid Home City: Home City is not valid Home State: Home State is not valid Home Zipcode: Home Zipcode is not valid Home Telephone: Home Telephone is not valid Business name (or college):* Business name (or college) is Required Website: Website is not valid Work Address: Work Address is not valid Work City: Work City is not valid Work State: Work State is not valid Work Zipcode: Work Zipcode is not valid Work Telephone: Work Telephone is not valid Work Telephone Extension: Work Telephone Extension is not valid Work Fax: Work Fax is not valid Check address you wish used for CPA mailing:* Check address you wish used for CPA mailing is Required Home Work Highest Earned Degree Note: If your highest degree was NOT granted by a department of psychology, AND you are not a member of the American Psychological Association, please include a transcript (official or student copy) of your graduate work.:* Highest Earned Degree Note: If your highest degree was NOT granted by a department of psychology, AND you are not a member of the American Psychological Association, please include a transcript (official or student copy) of your graduate work. is Required Institution:* Institution is Required Graduation Year:* Graduation Year is Required Location of Institution:* Location of Institution is Required Department:* Department is Required Program:* Program is Required States in which you are licensed or certified as a psychologist, including license/certificate #s:* States in which you are licensed or certified as a psychologist, including license/certificate #s is Required Have you ever been convicted of a felony?:* Have you ever been convicted of a felony? is Required Yes No If yes, provide conviction details.: If yes, provide conviction details. is not valid Do you have an ethics violation charge pending anywhere, or have you ever been charged with a legal ethical violation?:* Do you have an ethics violation charge pending anywhere, or have you ever been charged with a legal ethical violation? is Required Yes No If yes, provide ethics violation details.: If yes, provide ethics violation details. is not valid How many years, exclusive of training positions, have you been employed/practiced in the field of Psychology? :* How many years, exclusive of training positions, have you been employed/practiced in the field of Psychology? is Required Title/Position and Employer:* Title/Position and Employer is Required Immediate Supervisor:* Immediate Supervisor is Required % Time:* % Time is Required Since (yr.):* Since (yr.) is Required Previous Title/Position and Employer: Previous Title/Position and Employer is not valid Previous Immediate Supervisor: Previous Immediate Supervisor is not valid Work Setting: Work Setting is not valid Independent Practice Hospital Organizational Setting Academic Setting Community Agency Public/Private Mental Health Center Insurance Company If you are NOT licensed as a psychologist in Connecticut, AND are NOT an APA member (in the same category for which you are applying for CPA membership), we ask you to provide endorsements from two members of CPA, or one member of CPA and one member of APA. Please list the names and addresses of the individuals to whom you have given the enclosed endorsement forms. If you are not sufficiently familiar with two people who can endorse you, contact the CPA Central Office.: If you are NOT licensed as a psychologist in Connecticut, AND are NOT an APA member (in the same category for which you are applying for CPA membership), we ask you to provide endorsements from two members of CPA, or one member of CPA and one member of APA. Please list the names and addresses of the individuals to whom you have given the enclosed endorsement forms. If you are not sufficiently familiar with two people who can endorse you, contact the CPA Central Office. is not valid Reference 1 Address: Reference 1 Address is not valid Reference 2 Address : Reference 2 Address is not valid Check below if:: Check below if: is not valid You would like your email to be added to our mailing list You would like your email to be added to the CPA Early Career mailing list You would like to be contacted about getting more involved in CPA You would like more information about the Ethnic Diversity Task Force You would like more information about our Forensic Division You would like more information about the Connecticut Psychological Foundation Forensic Division - Additional Membership Price $50.00 (USD): Forensic Division - Additional Membership Price $50.00 (USD) is not valid Yes No Need More Information Areas of Interest: Areas of Interest is not valid Academic/Teaching ACOA ADD/ADHD/Learning Disabilities AIDS/HIV Affective Disorders Assessment/Testing Behavior Therapy Biofeedback Business Consulting Children & Adolescents Chronic Physical/Mental Illness Clinical Psychology Cognitive Psychotherapy/CBT Community Psychology/Prevention Consultation/Supervision Couples/Marital/Family Crisis Intervention Death/Dying/Bereavement Deafness Depression Developmental Issues Dialectic Behavior Therapy Disaster Mental Health Divorce Mediation/Custody/Visitation Dreams/Dreaming Eating Disorders EMDR Ethnic/Minority Issues Forensic Gay & Lesbian Geriatrics/Gerontology Group Therapy Health Psychology/Behavioral Medicine Hospital Practice Hypnosis Industrial/Organizational Infants Infertility Issues Men's Issues Intellectual Disability Neuropsychology/Brain-Behavior Personality Disorders Police Psychology Professional Issues/Advocacy Psychopharmacology Psychotherapy Psychotherapy (Adult) Psychotherapy (General) Psychotherapy (Individual) Psychotherapy (Psychodymanic) Rehabilitation Research School & Special Education Schizophrenia Sexuality Issues Short-Term Therapy Sport Psychology Substance Abuse Trauma/Abuse/Attachment Women's Issues Present membership status in APA:* Present membership status in APA is Required Fellow Member Associate Application Pending Student Affiliate None Year joined APA (approx. OK): Year joined APA (approx. OK) is not valid Institution in which enrolled:* Institution in which enrolled is Required Year entered:* Year entered is Required Certified Full-Time Student:* Certified Full-Time Student is Required Yes No Major Field:* Major Field is Required Degree Expected:* Degree Expected is Required Student Affiliate of APA? :* Student Affiliate of APA? is Required Yes No Applicants for Student Affiliate status who are NOT Student Affiliates of APA are asked to provide one sponsor's endorsement from a member of CPA. If there are no members at your institution, please request sponsorship from the chairperson of your department. Please list your sponsor's name and address here:: Applicants for Student Affiliate status who are NOT Student Affiliates of APA are asked to provide one sponsor's endorsement from a member of CPA. If there are no members at your institution, please request sponsorship from the chairperson of your department. Please list your sponsor's name and address here: is not valid I hereby certify that the statements made in this application are true and to the best of my knowledge and belief I am making voluntary application to the Connecticut Psychological Association for membership in the category indicated. I agree to be bound by the Ethical Principles of Psychologists, the Standards for Providers of Psychological Services, and other standards of professional ethics and practice adopted and published by the American Psychological Association or the Connecticut Psychological Association. I agree to be bound by the Constitution of the Connecticut Psychological Association as it is applicable to me as a member or affiliate. I authorize, whenever it may be deemed appropriate by CPA, the exchange of information concerning my application (before or at any time after action is taken on my application) with the American Psychological Association, other state psychological associations, or state licensing or certifying authorities. I authorize CPA to make inquiries as it deems appropriate in connection with this application for membership, with other individuals, agencies, organizations, or other reference sources as may be appropriate, and I authorize and invite anyone so contacted to respond freely and report fully and frankly any matter which may seem relevant to my application for membership in CPA. Enter Name:* I hereby certify that the statements made in this application are true and to the best of my knowledge and belief I am making voluntary application to the Connecticut Psychological Association for membership in the category indicated. I agree to be bound by the Ethical Principles of Psychologists, the Standards for Providers of Psychological Services, and other standards of professional ethics and practice adopted and published by the American Psychological Association or the Connecticut Psychological Association. I agree to be bound by the Constitution of the Connecticut Psychological Association as it is applicable to me as a member or affiliate. I authorize, whenever it may be deemed appropriate by CPA, the exchange of information concerning my application (before or at any time after action is taken on my application) with the American Psychological Association, other state psychological associations, or state licensing or certifying authorities. I authorize CPA to make inquiries as it deems appropriate in connection with this application for membership, with other individuals, agencies, organizations, or other reference sources as may be appropriate, and I authorize and invite anyone so contacted to respond freely and report fully and frankly any matter which may seem relevant to my application for membership in CPA. Enter Name is Required Today's Date: Today's Date is not valid Username:* Invalid Username Email:* Invalid Email Password:* Invalid Password Password Confirmation:* Password Confirmation Doesn't Match Password Strength * No val Please fix the errors above
