Therapist Member Application

Application for Therapist Membership


Name:

Office Addresses (street, unit, city, zip):

Preferred Mailing Address:

Office Phone(s):

(Optional)Home Phone:                                    Fax:                                            Additional Phone(s):
E-mail:


Educational Background

Institution and Field of Study:                                                                     Degree:

Additional Credentials, Training, Affiliations:

For referral purposes, please describe your therapeutic orientation and the nature of your therapy practice, include descriptions of your areas of specialty, the types of referrals you want, and referrals you do not want:

Number of cases you have worked with a surrogate partner? (circle) 0       1-5       5-10        11-19       20+
Sponsoring IPSA Member(s) with whom you have worked:

1.

2.

Mail application and $75.00 check for your first year dues to:
IPSA
3679 Motor Avenue, Suite 205
Los Angeles, CA 90034
For information or assistance, contact the Membership Committee.