Application for ALGBTIC Therapist Resource Listing
And Renewal Form

 

INSTRUCTIONS:  Fill out all applicable blanks, and then press the submit button. You must verify authenticity of your information.   Applicants must be current members of ALGBTIC, and membership will be verified. 

NAME - First: MI: Last:

ACA MEMBERSHIP NUMBER (will not be on listing):

HIGHEST DEGREE COMPLETED:

CERTIFICATIONS AND LICENSES:

PHONE NUMBER: ( ) - , Ext.

ALT. PHONE: ( ) - , Ext.

ADDRESS LINE 1:

ADDRESS LINE 2:

ADDRESS LINE 3:

CITY: STATE: ZIP:

EMAIL:

SERVICES RENDERED (i.e., general mental health with specialization):

BY PLACING MY EMAIL HERE I VERIFY THAT THE INFORMATION ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY ABILITY:

 

THANK YOU SO MUCH for your participation!  Questions regarding completing this form?  Email: rmate@purdue.edu