AUSTIN SOCIETY FOR PSYCHOANALYTIC PSYCHOLOGY

2016-2017

APPLICATION FOR MEMBERSHIP/RENEWAL OF MEMBERSHIP

Please complete the entire form even if you are renewing your membership.

All information listed below will be included in our online Membership Directory.

First Name ___________________________ Last Name_______________________________

Office Street Address ___________________________________________________________

Office City ______________________ Office State __________ Office Zip _______________

Office Phone ____________________ Office Fax ____________________________________

Email Address ___________________________________ Member of APA Division 39? Y N

Current Professional Employment _________________________________________________

Degree (please circle): MD DO PhD PsyD EdD MSW MA MS

Other: ______________________________

Licensure (please circle): MD DO PhD PsyD EdD LMSW LCSW LPC-I LPC LMFT LPA

Other: ______________________________

License Number: ______________________

Membership Categories

____ Full Member Annual Dues: $75

A full member is a mental health professional with a master’s degree or higher (e.g. psychiatrist,

psychologist, social worker or licensed professional counselor) with an interest in psychoanalytic

theory and treatment as evidenced by the pursuit of on-going education, research and/or professional

training in this area. Full members must also be licensed or certified, provisionally licensed, or license- eligible in their respective disciplines.


____ Student Annual Dues: First year free; $25 thereafter

Student members must be currently enrolled in an accredited academic mental health program.


Voluntary Contribution

____ ASPP encourages its full members to consider making voluntary monetary donations, in whatever

amount, to increase the organization’s ability to provide analytic training and/or research stipends to

students and early career professionals.

Total $ ___________

Signature _________________________________________________ Date ___________________

Mail to: ASPP

PO Box 162082 Austin, TX 78716

Please fill out or go to www.asppaustin.org to join or renew online.

Professional specialties:

(please check your top 6 for inclusion in the online directory)


_____Academic/Research Setting

_____Addiction/Substance Abuse

_____Adoption

_____Aging/Gerontology

_____Anger Management

_____Anxiety

_____Assault

_____Attention Deficit Disorder (ADHD) _____Autism spectrum

_____Bipolar Disorder/Mania

_____Body Image

_____Career counseling/Vocational

_____Child/Adolescent Behavior

_____Chronic Illness

_____Chronic Pain

_____Crisis Intervention

_____Deaf/Hearing Impaired

_____Depression

_____Developmental disorders

_____Dissociative Identity Disorder

_____Divorce

_____Domestic Violence

_____Eating Disorders

_____GLBT Issues

_____Grief and Loss

_____Impulse Control

_____Internet Addiction

_____Learning Disabilities

_____Life Transitions

_____Loneliness

_____Loss or Grief

_____Medication Management

_____Men’s Issues

_____Multicultural Issues

_____Obsessive-Compulsive Disorder (OCD)

_____Parenting/Family Concerns

_____Personality disorders

_____Phobias

_____Postpartum Issues

_____Psychological Assessment and Evaluation

_____Psychosis

_____Relationship issues

_____Self esteem

_____Self harm

_____Serious Mental Illness

_____Sexual Abuse

_____Sexual Concerns/Problems

_____Spiritual Issues

_____Sports Psychology

_____Stress Management

_____Suicidality

_____Trauma and PTSD

_____Underachievement

_____Women’s Issues

Other:___________________________________



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