Late Renewals Will Incur a $10.00 Fee

2015 MEMBERSHIP FORM - Return with fees by January 31st

(late renewals will incur a $10.00 fee)

Contact Information

Title:______Surname: ______Given Name: ______

Preferred Contact Info:

Address:______City/Town:______Postal Code:______

Phone: (P)______(C)______(O)______

Email(required): ______Fax: ______

Geographical area of work:

St. John’s/MetroAvalon Peninsula/EastCentral

WestLabradorOther ______

Please indicateany activities in which you are interested in participating.

APNL Committees/Reps

 Executive Continuing Education  Advocacy

NewsletterPsych Month Activities

Peer Counselling/Consult

 I am willing to provide peer counseling or consultation to fellow APNL members on a pro bono basis (Not intended as a means of psychological counselling or intervention)

Public Speaking

I am available to offer presentations or respond to requests to speak to:  Fellow Psychologists  Media  Public or Community Groups

on the following psychology related topic(s)/issue(s)

______

Signature: ______Date:______

For APNL Office Use Only
Date accepted: ______APNL#: ______
Receipt#: ______Fees Paid: ______
Notes: ______

Membership Renewals

For members who are, or have previously been, a member of APNL.

(For first time registration, please fill out section for new members on page 3)

Please indicate membership in the following (as applicable)

APNL# ______NLPB# ______CPA# ______

APA# ______CRHSPP#______Other______

Please select your membership category and the applicable fee:

Full Member

I am currently on the Full or Provisional Register with the Newfoundland Labrador Psychology Board (or equivalent Provincial/State Licensing Board)

I hold a graduate degree (Master’s or Doctorate) in Psychology acceptable to APNL

___ $200 Renewal postmarked before January 31st

___ $210Renewal after January 31st(including late fee)

CPA Member Discount (CPA #______)

___ $190 Renewal postmarked before January 31st

___ $200Renewal after January 31st(including late fee)

Student Member(**must meet both criteria**)

I am enrolled full-time in an academic institution pursuant to higher qualifications in Psychology as deemed appropriate by APNL Executive.

AND

I am not currently employed as a psychologist (Residents qualify for student membership)

___ $14 Renewal postmarked before January 31st

___ $24Renewal after January 31st(including late fee)

CPA Member Discount (CPA #______)

___ $13.30 Renewal postmarked before January 31st

___ $23.30Renewal after January 31st(including late fee)

New Members

*Note: If you are a NEW member applying after June 30th, you qualify for a 50% reduction of fees. Discount does not apply to existing APNL members. Please see Page 2 for requirements for membership categories (Full member and student member)

Sponsor’s Name (please print):
Note: must be an APNL member in good standing / Sponsor’s APNL #:
Sponsor’s Signature / Date:
EDUCATIONAL QUALIFICATIONS:
Highest Degree Obtained: ______Institution: ______
Specialty (ie. clinical, educational psychology, counseling psychology):
______
Date Anticipated/Completed: ______
Other University Education:
Institution: ______Degree:______
Completion Date: ______Specialty: ______

Please select your membership category and the applicable fee:

___ $200 New Full Member Registration between January 1st and June 30th

___ $100New Full Member Registration after July 31st

___ $14 New Student Registration between January 1st and June 30th

___ $7 New Student Registration after July 31st

CPA Member Discount (CPA #______)

___ $190 New Full Member Registration between January 1st and June 30th

___ $95 New Full Member Registration after July 31st

___ $13.30 New Student Registration between January 1st and June 30th

___ $6.65 New Student Registration after July 31st

Private Practice Directory (Optional)

(for members who are fully registered with the NL Psychology Board)

Please complete if you are work in private practice and would like your information published for public viewing on the APNL website. By completing this section, you are consenting to have your information published as written below.

Name: ______

Address: ______

______

Phone: ______Fax: ______

Email: ______

Website: ______

Gender: _____Male ____Female ____Other ____Prefer not to say

Highest Psychology degree obtained:______

Geographical area of work:

St. John’s/MetroAvalon Peninsula/EastCentral

WestLabradorOther ______

Client/Patient Population (check all that apply):

ChildAdolescent (12-15) Adolescent (5-19)

FamiliesAdult Couples

Senior Adult Other ______

Language:

Are you able to provide services in another language besides English? Y/N If yes, Please specify: ______

Areas of Practice:

__Abuse

__Emotional

__Physical

__Sexual

__Acute and Chronic

HealthProblems

__Addiction

__Substances

__Gambling

__Sex addiction

__Other

__Adoption Issues

__Anger Management

__Anxiety

__Assertiveness/ Social Skills

__Attachment Issues

__Attentional Problems/ ADHD

__Autism/ PDD

__Behavioural/ Parenting

__Blended Family

__Body Image

__Caregiver Stress

__Conflict Resolution

__Couples Therapy

__Depression

__Eating Disorders

__Grief/Loss/Bereavement

__Habit Change

__Learning Disabilities

__LGBT

__Obsessive Compulsive

Disorder

__Parenting

__Personal Growth/Wellness

__Personality Disorders

__Phobias/Fears

Areas of Practice:

__Physical Disabilities

__Rehabilitation – Cognitive/

neuropsych/brain injury

__Relationship issues

__Same Sex Couples

__Self-esteem

__Separation/Divorce

__Sex offenders

__Sex Therapy/Dysfunction

__Sexual Orientation

__Sleep Disorders/ Problems

__Stress Management

__Trauma/CISD/PTSD

__Workplace issues – Stress,

burnout, harassment

__Workshops

__Formal Assessment Services

__ ADHD

__Behav/Emotional

__Parental Capacity

__Career/Vocational

__Personality

__Custody Access

__Psychoeducational

__ Cognitive

__PTSD Assessment

__Legal/Forensic/

Insurance

__Consultations

__Neuropsychological

__Pain Assessment

__ Court/Litigation

__Alcohol- related

__Driving Suspensions