Affiliate Membership Form

* Denotes Required Field *First Name: *Last Name: *Degree: *Home County: *Office County: *Office Address Line 1:                                                                       *City: *State: *Zip: Office Phone: Second Office Address Line 1:                                                                                     City: State: Zip: Second Office Phone: Fax Number: Website: Email: Include email in print and website directory? YESNO NOTE: To save a significant amount of money and time, all correspondence is through e-mail, unless you check below. Please keep us informed of any changes to your e-mail address during the year. I need to receive a hard copy of correspondence by mail: YESNO Private Practice? YESNO If No, working setting: NJPA Member? YESNO Field of Study: Diplomate? *NJ License or Permit#: Permit Supervisor: Malpractice Insurance Company: Postdoctoral/Other Training/Certifications: Populations Served (Check all that apply)              Adolescents Adults Children Couples Families Gay, Lesbian & Bisexual Geriatrics Groups Individuals Primarily Females Primarily Males Supervision              Treatment Approach (Check all that apply) Art Therapy Behavior Therapy Biofeedback Cognitive Therapy Cognitive-Behavior Therapy Eclectic EMDR Existential Therapy Family Systems Gestalt Therapy Humanistic Hypnosis Interpersonal Play Therapy Psychoanalytic Psychodynamic Reality Therapy Short-Term Dynamic Solutions-Focused Therapy Supportive Therapy Areas of Practice and Clinical Focus: You may choose up to ten (10) areas of practice for your print directory listing (place check in left column). ACOA AD/HD (Adult) AD/HD (All Ages) AD/HD (Child) Addictive Behaviors Adolescent Issues Aging AIDS/HIV Infection Alcohol and Drug Abuse Anger Anxiety Disorders Asperger's Disorder (Adult) Asperger's Disorder (All Ages) Asperger's Disorder (Child) Attachment Disorders Autism Behavioral Medicine Biofeedback Bipolar Disorder (Adult) Bipolar Disorder (All Ages) Bipolar Disorder (Child) Borderline Personality Disorder Brain Injured/Head Trauma Cancer Cardiac Rehab/Risk Reduction Child Abuse Child Custody Evaluations Children Chronic Illness Conduct Disorders Death and Dying Depression Developmental Disability (Adult) Developmental Disability (All Ages) Developmental Disability (Child) Dietetrics and Nutrition Disability Evaluations Dissociative Disorders Divorce Mediation Eating Disorders Elder Abuse Elimination Disorders Forensics Gambling Headaches/Migraines Health and Fitness Hearing Impaired Individuals Industrial/Organizational Infertility Management Development Training Media Psychology Men's Issues Mindfulness Mood Disorders Motivation/Personal Achievement Neuropsychological Assessment (Adult) Neuropsychological Assessment (All Ages) Neuropsychological Assessment (Child) Obesity OCD (Adult) OCD (All Ages) OCD (Child) Pain Management Panic Disorders Parenting Personality Disorders Phobias Physically Handicapped Post Traumatic Stress Premarital Therapy Psycho-educational Testing and Assessment (Adult) Psycho-educational Testing and Assessment (All Ages) Psycho-educational Testing and Assessment (Child) Psychological Testing and Assessment (Adult) Psychological Testing and Assessment (All Ages) Psychological Testing and Assessment (Child) Psychotic Disorders Rape/Victimization Relationship Issues Religious Issues School Psychology Self-Injurious Behavior Sexual Disorders Sexual Orientation and Identity Sexuality Sleep Disorders Smoking/Tobacco Cessation Social Anxiety Disorder Social Skills Training Sports Psychology Suicide Trauma Trichotillomania Vocational Counseling Women's Issues Work Issues Statement (to be included in print directory) The Morris County Psychological Association (MCPA) is an interest group of licensed psychologists and is not a certifying organization. The Association, therefore, does not make specific referrals, but does make its list of licensed psychologists and areas of practice available for the interests of the public. MCPA also takes no responsibility for areas of practice and other information identified by members who have chosen to be part of this directory. This list of licensed psychologists does not include and does not intend to confer opinions, ratings, or reviews of participating professionals. MCPA assumes no responsibility with respect to the selection of a psychologist and the outcome of the therapy. The absence of the name of a licensed psychologist from this list in no way implies that they are not a competent psychologist; it only implies that they do not participate in this particular service. MCPA makes no representation with respect to the success of treatment and assumes no responsibility for the results of therapy or the associated costs. Options to pay the $55 membership fee will be presented upon clicking the submit button.