MICHIGAN PSYCHOANALYTIC COUNCIL

 APPLICATION FOR MEMBERSHIP

 

 

Name ___________________________________________________Credentials____________________

 (As you wish your name and credentials to appear in the membership directory)

Primary Mailing Address  _________________________________________________________________

 

Secondary Address _____________________________________________________________________

 

Primary phone   _____________________________ Secondary phone ____________________________

 

E-mail address (print clearly) ______________________________________________

 

Educational Background:

Institution                                                               Degree                      Date                         Major

 

_____________________________________________________________________________________

_____________________________________________________________________________________

Current Positions:    _____________________________________________________________________

_____________________________________________________________________________________

 

Are you currently certified in Psychoanalysis:   _________yes    _________no

 

Are you interested in training and certification in Psychoanalysis through MPC    _______yes    ________no

 

Please describe your interests in Psychoanalysis (course work, independent study, teaching, other):

 

_____________________________________________________________________________________

_____________________________________________________________________________________

 

Professional areas of interest (check all that apply)    ______adult ______adolescents ______children

_____forensic  _______neuropsychology  _______marriage & family ________substance abuse

 

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MEMBERSHIP CATEGORIES:

 

Full members:          We welcome all persons interested in Psychoanalysis

Retired/Inactive:       Those who no longer practice yet wish to affiliate with MPC

Student:                   Graduate students or psychiatric residents.

 

Please indicate status for which you are applying:

 

_________Full Member (Annual dues $125.00)  Note: Greatly reduced dues are offered to new professionals who have graduated within the past three years. Please ask for more information if you would like this option.

_________Retired/Inactive Member (Annual dues $50.00)

 

_________Student Member (Annual dues $40.00)  Note: Waiving of annual dues is offered to student members upon request.  

 

Please return this application and dues to:  (make check payable to Michigan Psychoanalytic Council)

Elizabeth A. Waiess, PsyD

PO Box 4402                                                                       

East Lansing, MI  48826                                                 

800-218-9130                                                              

mpcpsa.org

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For Administrative Purposes:

 

Date Received _________________________

 

Dues forwarded ________________________

 

Welcome letter prepared _________________

 

Listserv Updated   ______________________

 

Website updated _______________________

 

New Member Luncheon invitation __________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4/06