Austin Psychoanalytic Membership

Select the level of Membership*

Full Member $150 annuallyFull time Graduate Student or Retiree - $75 annually
Full Name*

First NameLast Name
Licensure
(PhD, LCSW, LPC, LMFT, etc.)
E-mail*
Are you a member of Division 39 of the American Psychological Association*

YesNo

Address (as you want it to appear in the Membership Directory)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (as you want it to appear in the Membership Directory)

Area CodePhone Number
Alternate Phone Number (Will not appear in Membership Directory)

Area CodePhone Number
Professional website
Our online Membership Directory listing all members who want to be listed will include name, address, phone number, e-mail address, website, population served, and areas of specialization.

I want to be listed in the Directory.I want to be listed in the Directory but do not include my email address.I do not want to be listed in the Membership Directory.
Population(s) Served: Check all that apply

ChildCouplesFamilyAdultElderlyGroupsAdolescent
Specialty Areas: (Please list)
Volunteering
Check below if you are interested in volunteering to serve in one of the following areas:

Membership and recruitmentEvent logisticsCommunications and PublicationsPublicity and Community Liaison and OutreachExecutive Committee board memberOther
Payment

Memberships will auto-renew annually until you notify Austin Psychoanalytic (info@austinpsychoanalytic.org) to stop payment. If paying by check, please complete the form online and indicate you are sending a check. Please have check made out to Austin Psychoanalytic and mail to P.O. Box 162082, Austin, TX 78716.
Payment Options*

Credit Card with auto-renewCheck by mail

Volunteering