|
SEPI Membership Application The Society for the Exploration of Psychotherapy Integration has set annual dues for this year of $59 U.S. for regular members, and $29 U.S. for full-time students. Dues include a subscription to SEPI's journal, the Journal of Psychotherapy Integration. Name________________________________________________ Street Address_________________________________________ _____________________________________________________ City______________ State____Zip________ Country______________________________ Home Phone_____________________________________________________ Office Phone __________________________ FAX Number_____________________________ E-Mail address___________________________ Highest degree earned___________________ Student? Yes_____ No______ Engaged in clinical practice? Yes ___No___ For North American members: State or province, discipline, and number of license: _________________________________ Please note: License information will not be published, but a practice will not be listed unless the appropriate license is held. Patient population you work with (check all appropriate categories): AGES: Under 12__ 12-17__ 18-65__Over 65__ APPROACHES: Individual__ Family__ Couples__ Group__ Hypnosis__ Sex Therapy__ Psychopharmacology__ Payment can be by check drawn on a U.S. bank, and made out to SEPI. To pay by credit card, fill out the following: Type of credit card (check one): VISA__ MasterCard__ American Express__ Credit card number:____________________________ Expiration date:_____ Signature:_________________________ Mail to: Dr. George Stricker For further information, e-mail George Stricker: geostricker@comcast.net |