LMH Individual Membership Registration Form

APPLICATION FOR MEMBERSHIP

Please complete this form thoroughly and truthfully. For detailed information on the eligibility requirements for the different types of membership, visit our official website at livencepsych.com. This form will be automatically received by the Center. Within this form, we will also be asking you to upload your updated curriculum vitae or résumé and a recent formal headshot.
Personal Information
Name*

First NameMiddle Name (Optional)Last NameSuffix
E-mail*
example@gmail.com
Phone Number*
Format: (+63) 000-0000-000.
Address*

Street Address

Barangay

City/MunicipalityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Employment Details
Current Job Title*
Employer*
Work Address*
Please type in the Barangay, City/Municipality, and Province where your work is located.
Employer's Contact Number*
Please enter a valid phone number.Format: (+63) 000-0000-000.
Number of Years at Current Work*
Educational Background
Highest Educational Attainment*

High School LevelAssociate DegreeBachelor's DegreeMaster's DegreeDoctorate Degree
Date of Conferment of Highest Degree *

MonthDayYear
Date
Last School Attended*
Professional Licenses/Certifications*
Please indicate the license/certification and the awarding body/organization (e.g., Registered Psychologist, PRC)
Membership Details
Membership Type*

Basic Membership (PHP 1,500.00)Professional Membership (PHP 3,000.00)
Which areas of trauma-informed practice are you most interested in?

Trauma Assessment and ScreeningTrauma-Sensitive Communication and EngagementPsychoeducation on TraumaTrauma-Informed InterventionsVicarious Trauma and Traumatic Stress ManagementCultural Competency and Trauma-Informed CareResilience and Posttraumatic GrowthSafety Planning and Crisis InterventionTrauma-Informed SupervisionOrganizational/Workplace TraumaTrauma Advocacy and Systems Change
Document Uploads
Upload CV/Résumé*
Upload Recent Formal Headshot*
Payment Details

Please note that all payments are NON-REFUNDABLE AND NON-TRANSFERABLE.
Payment Method*

Bank Transfer via Metrobank (Account Name: Livence Psychological Services; Account No.: 313-3-31397966-1)GCash (Account Name: Ron Gabriel Peji; Account No.: 09754590712)Maya (Account Name: Ron Gabriel Peji; Account No.: 09754590712)
Upload Proof of Payment*
Logistics
How did you hear about us?*

A friend or colleaugeGoogleBlog postFacebookOther
Acknowledgement and Consent
Agreement to Membership Guidelines and Policies*

I have read, understood, and agree to abide by the guidelines, policies, and terms of membership as set forth by Livence Center for Psychotraumatology. I acknowledge that failure to comply with these guidelines may result in the rejection, suspension, or termination of my membership.
Opt-in for Email Updates and Newsletters*

Yes, I would like to receive regular updates, newsletters, and announcements regarding upcoming events, workshops, and resources from Livence Center for Psychotraumatology.No, I do not wish to receive email updates and newsletters.
Certification of Information Accuracy*

I hereby certify that all the information provided in this application is accurate and truthful to the best of my knowledge. I understand that providing false or misleading information may result in the rejection of my membership application or the termination of my membership.
Once you submit this form, Livence Center for Psychotraumatology will review your application. Please wait for approximately 5-7 working days for the decision of the Center that will be sent to you via email.

Thank you!
Should be Empty:

APPLICATION FOR MEMBERSHIP

Personal Information

Employment Details

Educational Background

Membership Details

Document Uploads

Payment Details

Logistics

Acknowledgement and Consent