MICHIGAN PSYCHOANALYTIC COUNCIL

 APPLICATION FOR MEMBERSHIP

 

 

Name ___________________________________________________Credentials____________________

 

Primary Address ________________________________________________________________________

 

Secondary Address _____________________________________________________________________

 

Primary phone (___)_______________________ Secondary phone (____)_____________________

 

E-mail _____________________________ Fax # ________________________ Birth date_____________

 

Educational Background:

Institution                                                      Degree                Date            Major

 

_______________________________      ________           ______         __________________________

 

_______________________________      ________           ______         __________________________

 

Current Positions (s) _____________________________________________________________________

_____________________________________________________________________________________

 

Are you currently certified in Psychoanalysis:   _________Yes    _________No

 

Are you interested in training and certification in Psychoanalysis:  ________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 Members:    Those who no longer practice, yet wish to affiliate with MPC.

Student Members:                 Shall be graduate students or psychiatric residents.

 

Please indicate status for which you are applying:

 

_________Full Member (Annual Dues $125.00)*

 

_________Retired or Inactive Member (Annual Dues $50.00)

 

________ Student Member (Annual Dues $40.00)  Expected date of graduation __________

 

(*)  For professionals who have been out of school less than three years and cannot afford the full annual dues, reduced annual dues are available.  Please ask the membership chairperson about this. 

 

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

 

Elizabeth A. Waiess, PsyD                                                       MPC Dues are NOT tax deductible as a

PO Box 4402                                                                             charitable contribution, but may be a

East Lansing, MI  48826                                                            deductible business expense.

800-218-9130                                                              

mpcpsa.org

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For Administrative Purposes:

 

Date Received _________________________

 

Dues forwarded to Treasurer  _____________

 

Welcome letter prepared _________________

 

Welcome letter mailed out ________________

 

Copy of Application _____________________

 

New Member Luncheon attended __________

 

Directory Updated ______________________

 

Listserv Updated   ______________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4/06