AUSTIN SOCIETY FOR PSYCHOANALYTIC PSYCHOLOGY
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
Licensure (please circle): MD DO PhD PsyD EdD LMSW LCSW LPC-I LPC LMFT LPA
License Number: ______________________
____ 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.
____ 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.
(please check your top 6 for inclusion in the online directory)
_____Attention Deficit Disorder (ADHD) _____Autism spectrum
_____Dissociative Identity Disorder
_____Grief and Loss
_____Loss or Grief
_____Obsessive-Compulsive Disorder (OCD)
_____Psychological Assessment and Evaluation
_____Serious Mental Illness
_____Trauma and PTSD