Join or Renew Form

HPS Join or Renew Form
- Membership Type
  
  Active Member $150Student Member $25 (Student members shall be full-time students and/or in full-time training programs.)Pay by Check
- Total
- Payment*
  
  prevnext( X )
  USDDescription
- Student members shall be full-time students and/or in full-time training programs.
- Are you enrolled in a full-time clinical training program expected to lead to licensure?*
  
  YesNo
- Name of educational institution*
- Degree expected*
- Name*
  
  First NameLast Name
- Licensure*
  (i.e.: MD, PhD, LCSW, LMSW, LMFT etc.)
- Email*
  example@example.com
- Phone Number
  
  Area CodePhone Number
- Business Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Professional Website
- Are you a dues-paying, Active Member, voting member of APsaA - American Psychoanalytic Association?*
  
  NoYes
- In the last 12 months, has your license ever been suspended, revoked or limited by a state licensing board?*
  
  NoYesNot applicable
- In the last 12 months, have you been involved in a legal action related to your work or had any malpractice claims or suits filed against you?*
  
  NoYes
- In the last 12 months, have you been involved in an ethical charge in relation to your professional work?*
  
  NoYes
- In the last 12 months, have you been convicted of a felony?*
  
  NoYes
- If you answered "yes" to any of the above ethics questions, please give a detailed explanation in the space provided below.*
- HPS Online Membership Directory
  
  This is a listing of all members who wish to be listed in the online directory and includes name, address, phone number, website, population served and areas of specialization. Please do not to list your home address.
- Online Membership Directory Listing*
  
  I would like to be listed in the directory.I would NOT like to be listed in the directory.I would like to be listed, but do not want my address included in the directory.
- Populations Served
- Population Served: check all that apply
  
  AdultAdolescentChildCouplesElderlyFamilyGroups
- Specialty Areas: (please list)
- Volunteering
- Check below if you are interested in volunteering to serve in one of the following areas.
  
  Communications and PublicationsEvent LogisticsFilm SeriesMembership and RecruitmentPublicity and Community LiaisonPublicity and Community Outreach
- Comments and Feedback are welcome and appreciated.
- By submitting this form, I acknowledge that I will abide by the standards, rules and regulations of the Houston Psychoanalytic Society.
  
  I understand my membership is not active until payment has been processed.
- You have indicated that you would like to mail a check. Please print your completed application and mail with your check to:
  
  Houston Psychoanalytic Society
  Attn: Kim Haq
  1302 Waugh Dr. #276
  Houston, TX 77019
- Should be Empty:

HPS Join or Renew Form

HPS Online Membership Directory

Populations Served

Volunteering