All active VTMHCA members will be included in our directory listing as a part of membership. Your contact information and "Characterizing Your Practice" will be accessible to visitors who are looking for a therapist on the VTMHCA.org website.

Please Note: All information marked with an asterisk (*) is visible on your directory listing. Home address and phone will not be displayed unless it is your workplace and you insert it into Office fields.

We suggest you review some of the completed listings prior to filling out the form below.

New Joining Members:

Complete the membership form below, click “Join Now” and choose payment method.

• Choosing a region is essential for new clients to find you
• Your listing will not appear until your payment is received

You may pay by PayPal or mail a check.

Fields in red are required.

Personal Information
*Last Name:	First Name:
Middle Initial: Home Address:
Town/City:	State: Zip:
Home Phone:	Email1 (Personal):

Professional Information
*Company Name or Place of Employment:
*Office Address:
*City:	*State: *Zip:
*Email2 (Office):	Cell or Other Phone:
*Office Phone:	Fax:
Work Setting:	Private Practice Hospital Non Profit Agency Alternative Ed.
*Website: http://

Membership Information
Membership Level: Full Clinical 2 years at savings rate of $160.00 Clinical $100.00 Associate $60.00 Retired $25.00 Student $25.00
Are you a student?	Yes  No
If you are a student, enter your professor's name for verification
Region: (hold down Ctrl while clicking to select multiples) Burlington & area (Essex, Williston, Winooski) Central (Montpelier, Waterbury, Randolph & area) Eastern (Springfield, White River & area) Southern (Brattleboro, Bennington & area) Northern (St. Johnsbury, NEK & area) Northwestern (St. Albans, Lamoille & area) Western (Rutland, Middlebury & area)
Are you a member of AMHCA?	Yes   No
Unified Dues Program: Join both VTMHCA & AMHCA and receive a 20% discount on both memberships. For more information and to join both, please go to: www.amhca.org/join/ (This link will open a new window so that you may retain this website in this browser window. Please complete this form first and then proceed to AMHCA membership.)
*List any degrees that you hold:
*List any other pertinent education:
*List other associatons in which you hold membership:
*Select any licenses you hold.   (hold down Ctrl while clicking to select multiples)	LCMHC LICSW LADC LMFT MD NCC Psychologist-MA Psychologist-Doc RN RPT RPT-S
*Areas of Experience: (use Ctrl to select multiples) Assessment Art Depression/Grief/Loss Anxiety/Phobia/OCD PTSD Schizophrenia and Bipolar Disorders Sexual Dysfunctions Addictions Medical, Rehabilitational, Pain Problems Marital and Family Issues Childhood Disorders and School Problems Sports Counseling EMDR Organizational and Business Consultation Career Development Elder Issues Health Hypnotherapy Pastoral Play Supervision Unspecified

Characterizing Your Practice *Counselor Type: (select all that apply)
Adults Adolescents Children Elders	Individual Couple Family Group
*Give us a brief explanation of your philosophy (max 255 characters)
*Type of Therapy
*Years in Practice
*What's the best way to schedule an appointment? (select all that apply)	Call Email Write
*Payment Types Accepted: (select all that apply)	Cash Credit Card Check Other
*Do you accept insurance?	Yes  No
*Types of Insurance Accepted:

Directory Information
Choose a UserID: (for future editing capability)
Choose a Password:
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