SOCIETY OF PSYCHOTHERAPIST
MEMBERSHIP CHAIR:
Nelkia Torrez, PH.D.
3650 James St, Syracuse, NY 13206
EMAIL: NtorrezNY@aol.com
APPLICATION FORM FOR MEMBERSHIP
PLEASE PRINT OR TYPE ALL INFORMATION
Name____________________________________________
Age_________ Sex_____________
Total Years of Experience____________ License/State______________License #_________________
Profession_________________________________ Email/Address ____________________________
Business Address____________________________________________________________________
City____________________________State__________Zip____________Phone_________________
Home Address______________________________________________________________________
City____________________________State___________Zip___________Phone_________________
EDUCATION:
Institution (undergraduate, graduate,
and other institutions)
Dates Major Field(s)
Degree
_________________________________________ __________ _______________ _______________
_________________________________________ __________ _______________ _______________
_________________________________________ __________ _______________ _______________
INTERNSHIP, RESIDENCIES, TRAINEESHIPS, ETC.:
Institution or Agency Dates
Type of work performed
______________________________________ __________ _________________________________
______________________________________ __________ _________________________________
PROFESSIONAL AFFILIATION:
APA AGPA
AMA NASW NAMFT
AAPC NBCC NACCMHC
OTHER____________________________________________________________________________
PAID EXPERIENCE TO DATE:
Institution, Agency, or Private
Practice devoted to Psychotherapy
Dates Hrs./Wk. Type
of Work Aver. Hrs./Week
______________________________ _______ _______ _________________ __________________
______________________________ _______ _______ _________________ __________________
______________________________ _______ _______ _________________ __________________
______________________________ _______ _______ _________________ __________________
______________________________ _______ _______ _________________ __________________
PERSONAL PSYCHOTHERAPY:
Therapist
Orientation Total *Type
Dates
(full name and degree)
no. of hours
1. Name__________________________________
Address__________________________________ ____________ _______ __________ ________
City______________State_____Zip___________
2. Name__________________________________
Address__________________________________ ____________ _______ __________ ________
City______________State_____Zip___________
PSYCHOTHERAPY SUPERVISION:
Please list Supervisors chronologically
Orientation No. of *Type
Dates
Please give complete and current address
hours spent
with supervisor
1. Name_________________________________
Address__________________________________ ____________ ________ __________ _______
City______________State_____Zip___________
2. Name_________________________________
Address__________________________________ ____________ ________ __________ _______
City______________State_____Zip___________
3. Name_________________________________
Address__________________________________ ____________ ________ __________ _______
City______________State_____Zip____________
PSYCHOTHERAPY SUPERVISION (con't):
Please list Supervisors chronologically
Orientation No. of *Type
Dates
Please give complete and current address
hours spent
with supervisor
4. Name_________________________________
Address__________________________________ ____________ ________ __________ _______
City______________State_____Zip___________
Date________________________Signature________________________________________________
Please remember to enclose the $50.00 application fee. A separate sheet may be used for other
pertinent information.
