Mental Health Professional Application

FINANCIAL PROFESSIONAL

APPLICATION FOR MEMBERSHIP
NAME*
NAME OF FIRM*
ADDRESS*
OFFICE NUMBER*
CELL PHONE NUMBER*
FAX
WEBSITE ADDRESS
EMAIL ADDRESS*
example@example.com
LICENSE NUMBER*
YEARS OF PRACTICE*
AREA OF SPECIALIZATION
YEARS OF PRACTICE IN SPECIALTY
PROFESSIONAL LICENSES
ARE YOU A CERTIFIED FAMILY MEDIATOR*
ORIGINAL YEAR OF CERTIFICATION
THREE REFERENCES - Please provide name, email address and daytime telephone number. Please include (2) two references of whom are members of CFLI and (1) one of whom is practicing in your field.*
Our dues are $200.00 for Mental Health Professionals and they are due on January 1st of each year. The dues for the first year will be prorated. All approved applicants will be required to participate in a Collaborative training within 90 days of approval of membership. If you are approved for membership you agree to comply with the CFLI's By-Laws, attend all CFLI general meetings (unless excused), meet all continuing education training requirements and remain current in payment of dues.

Once complete please submit application fee of $25.00 through the payment portal on our website.

If paying via check pelase send to:

Mr. Philip Herzberg, CFP®, CDFA®
2375 NE 213th Terrace
Miami, FL 33180

If you have any questions, please contact:

Tricia Cassel, CFLI Membership Chair at drcassel@triciacassel.com

CFLI Rules and Regulations are available online at www.collaborativefamlaw.com

I HAVE READ THE CFLI MEMBERSHIP RULES AND REGULATIONS:
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FINANCIAL PROFESSIONAL