Indiana Psychological Association Students

New Member Application

Complete this form and click "Submit" to send your application.

Contact Information

Title & Name (first, middle, last, degree)	Title (Dr.,Ms., etc.) Name (First, Initial, Last) A value is required.
Practice Street address		City
State		Zip
County		Phone
Email		Use as Primary Contact	Yes No

Home Street address	City
State	Zip
County	Phone
Email	Use as Primary Contact	Yes No

Demographic Information

Gender (Optional)	Male Female
Ethnicity (Optional)	African American Asian Caucasian/White East Indian Hispanic/Latino Middle Eastern Native American Pacific Islander Interracial
Languages spoken fluently

Do you give IPA permission to publish your practice information on the IPA web site?	Yes	No
Would you prefer to receive the quarterly IPA Newsletter by email?	Yes	No
Are you willing to be interviewed as an IPA Featured Member for the newsletter and web site?	Yes	No

Training and Certifications

APA/APAGS Member?	Yes No
Indiana Professional License Number
Year Highest degree conferred
Graduate school, city and state
Internship site, city and state
Post-doctoral site, city and state
HSPP Certified?	Yes No
Board Certified?	Yes No. If yes, which?

Practice Information

Age groups served

0-12

13-17

18-64

65+

Services offered

Individual Psychotherapy
Couples Therapy
Family Theapy
Group Therapy
Parent Mediation
Psychological Testing
Forensic Assessment

Assessment types

Adult Neuropsychological
Pediatric Neuropsychological
Psychoeducational
Vocational/Disability
Custody Evaluation
IQ
Personality

Conditions treated

Abuse/Trauma

Addictions

Anger

ADD/ADHD

Autism Spectrum

Borderline P.D.

Brain Injury

Chronic Pain

Conduct Disorders

Depression/Mood Disorders

Eating Disorders

Learning Disability

OCD/Anxiety

Psychosis/Schizophrenia

Sexual Dysfunction

Smoking Cessation

Other (note below)

Any additional biograaphical information you wish included on your profile?

Attestation:

Have you ever been convicted of a felony or disciplined for a violation of the Ethical Principles of Psychologists and the Code of Conduct of APA?

Yes
No

Are you currently under investigation for a felony or an alleged violation of the Ethical Principles and Code of Conduct?

Yes
No

I agree to become bound by the ethics of professional psychology not only as currently endorsed by the profession, but also by the standards of practice that shall be adopted from time to time by APA. I understand it would be a violation of APA ethical standards to use membership in IPA as a credential for professional training. I authorize, whenever appropriate, the exchange of information concerning my application with APA, with state psychological associations and with state licensing or certifying authorities. I authorize IPA, its officers, its members or it agents, to verify my professional standing and my education credentials.

I attest that the information in this application is accurate and complete to the best of my knowledge.

Name Name is required. Date A date is required.