2024 Net Membership Application

2024 NET Membership Application Annual Membership

January - December 2024

Please fill in all areas that help describe your organization and/or private practice.
The information below is for NET Website Listing and IS PUBLIC (omit any info you do not want listed on NET website):
Name

First NameLast Name
Credentials
Business/Organization Name
Business Address
City
State
Zip
Business Phone
Business Email
example@example.com
Website
For LPC Interns Only:
Name of Supervisor, if applicable
What Populations do you serve?

ChildrenTeens 13 to 17Adults 18 and upGeriatric over 60IndividualsCouplesFamiliesGroup WorkOther
For Corporate Members, what services do you provide?

Inpatient servicesDetoxInpatient RehabResidential ServicesPartial Hospitalization (Mental Health)Partial Hospitalization (Substance Use Disorder)Intensive Outpatient Program (Mental Health)Intensive Outpatient Program (Sustance Use Disorder)Outpatient Counseling ServicesOther
How do you provide care:

In-PersonVirtuallyBoth
What insurances do you accept:

BCBSAetnaCignaHumanaUnited Health CareMagellanOptumTraditional MedicaidManaged Medicaid Plan, please call specificsTraditional MedicareManaged Medicare Plans, please call for specificsTri-Care, please call for specificsSliding ScaleSelf pay - check other and list price in"other" sectionOther
What clinical interests do you treat?

Depression/Mood DisorderAnxiety/Stress/Panic AttacksPost Traumatic Stress DisorderWomen's IssuesMen's IssuesGrief/LossTraumaCrisis InterventionCourt Related Services/MediationAngerDomestic ViolenceRelationship/Separation/Divorce/Blended FamiliesEating Disorders/Disordered EatingAddictions (check other and be specific in "other" section)Other
What type of membership is this?

New Individual Membership (50.00- haven't been a member for over two years)New Student (25.00 - type year of graduation in other box)New Corporate Membership (100.00 - up to two attendees per month)Renewing Individual (50.00)Renewing Student (25.00 - type year of graduation in other box)Other
How will you be paying?

Credit Card (pay below)Cash at next meetingMailing CheckCheck at next meeting

This section is for Credit Card Users only. If paying by check or cash, skip to submit.

New Individual Membership Haven't been a member the previous two years or more.

$50.00

Renewing Individual Member

$50.00

Corporate Membership

$100.00

New Student Membership

$25.00

Renewing Student Membership

$25.00

Total

$0.00

Credit Card

Should be Empty: