Licensed Member - $325.00 / Recurring - Connecticut Psychological Association

Automatically renews annually! This membership category is for licensed psychologists who are ten years post-degree.

Terms:

$325 / Year

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: (By inviting members to self-report their gender identify (diversity data), CPA facilitates an evidence-based approach to advancing equity, diversity, and inclusion (EDI). By analyzing diversity data, CPA aims to increase diversity and inclusion in our community, organizational processes, remediate unfair bias, and drive greater equity in psychology more broadly.):* Gender: (By inviting members to self-report their gender identify (diversity data), CPA facilitates an evidence-based approach to advancing equity, diversity, and inclusion (EDI). By analyzing diversity data, CPA aims to increase diversity and inclusion in our community, organizational processes, remediate unfair bias, and drive greater equity in psychology more broadly.) is Required

Female Male Transgender Nonbinary Other Prefer not to say

Birth Date:* Birth Date is Required

Ethnicity: (By inviting members to self-report their ethnic origins and race (diversity data), CPA facilitates an evidence-based approach to advancing equity, diversity, and inclusion (EDI). By analyzing diversity data, CPA aims to increase diversity and inclusion in our community, organizational processes, remediate unfair bias, and drive greater equity in psychology more broadly.):* Ethnicity: (By inviting members to self-report their ethnic origins and race (diversity data), CPA facilitates an evidence-based approach to advancing equity, diversity, and inclusion (EDI). By analyzing diversity data, CPA aims to increase diversity and inclusion in our community, organizational processes, remediate unfair bias, and drive greater equity in psychology more broadly.) is Required

If Biracial/Multi-ethnic/Other please specify: If Biracial/Multi-ethnic/Other please specify is not valid

Home Address:* Home Address is Required

Home City:* Home City is Required

Home State:* Home State is Required

Home Zipcode:* Home Zipcode is Required

Home Telephone:* Home Telephone is Required

Business name (or college):* Business name (or college) is Required

Website: Website is not valid

Work Address:* Work Address is Required

Work City:* Work City is Required

Work State:* Work State is Required

Work Zipcode:* Work Zipcode is Required

Work Telephone:* Work Telephone is Required

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 not valid

Department: Department is not valid

Program: Program is not valid

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

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

Work Setting:* Work Setting is Required

Independent Practice Hospital Organizational Setting Academic Setting Community Agency Public/Private Mental Health Center Insurance Company

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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

Present membership status in APA: Present membership status in APA is not valid

Fellow Member Associate Application Pending Student Affiliate None

Year joined APA (approx. OK): Year joined APA (approx. OK) 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

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Send Check Payments to: ATT: Connecticut Psychological Association (CPA) PO Box 1167 Old Saybrook, CT 06475

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