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MEMBERSHIP APPLICATION                                                                Print Application  getacro.gif (2135 bytes)

Title:_____ First Name:_____________________ Middle Initial:___

Last Name:___________________________________________(include professional degree)

(Agency or Affiliation if Applicable):_______________________________________________________________

Street Address:____________________________________________________________

City_____________________________________ State:_________________ Zip Code:_______

Please indicate whether the address above is your:___ Home Address or ___ Business Address

Daytime Phone:____________________ Fax :_____________________

Email :______________________________ Repeat Email ______________________________ 

Please enter Email address carefully. We will use it to send confirmation of your application.

PROFESSIONAL BACKGROUND

In order for your application to be processed, you must answer ALL questions COMPLETELY

1. Type of Credentials:

___RN ___LPC ___LSW ___LCSW ___LMFT ___PhD ___MD

___ Other - Please specify______________

License No. (If applicable) ______________ State _______

2. How many years of experience do you have in providing anger management services?:_______

3. With how many clients are you currently working?____ 1-10 ___ 11-20 ___ 21-30 ___ 30 or more

4. Years of experience providing anger management service:___ 1-3 ___ 4-6 ___ 7-10 ___10 or more

5. Please check all areas of interest for future trainings. (You may check multiple fields)

___ Anger Management Updates in Treatment ___ Couples Anger Management ___ Children & Anger ___Group Work ___ Adolescent Anger Management ___ Parenting & Anger ___ Other:_______________________________________________

6. Would you be willing to provide outcome survey information measuring benefits of your work?                   ___ Yes ___ No

7. Please indicate if you work for:

____ Agency ____ Private Practice

8. Are you willing to volunteer to provide time and leadership for NAMA?___ Yes ___ No

Please Specify:________________________________________________________________________

9. How did you hear about NAMA?

___ NAMA Website ___ Direct Mailing ___  Email ___ Professional Journal ___

Word of Mouth ___ Other - Please specify____________________________________________________

10. Please include one copy of your Resume or CV with this application. 

11. Which Membership Level are you applying: (One year dues covers application fee & first year membership)

__Professional Level __Fellow Level __ Diplomate Level __Student Level __Agency

     (Dues: $75/yr)     Dues: $100/yr)    Dues: $200/yr)  (Dues: $25/yr)  (Contact the NAMA office)

                                                                                                                                                                                   mailto:namass@namass.org

Checks payable to: NAMA, 2753 Broadway Suite 395, New York, NY 10025

Print Application  getacro.gif (2135 bytes)

Contact Information

Email
General Information: namass@namass.org

                         

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