Renewing or
New Member:
Please select one:
Select Status
Renewing Member
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Please complete
all contact information:
Name:
Degree:
License #:
Year Licenced:
Business Address:
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State:
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Membership
type (select one):
Full Member or Instituitional:
Licensed
Please Select
1st year 50% off $62.50
PhD $125
PsyD $125
EdD $125
Doctoral:
Unlicensed
Please Select
1st year 50% off $32.50
PhD $65
PsyD $65
EdD $65
Associate Member:
Please Select
1st year 50% off $52.50
MA $105
MTF $105
LCSW $105
Affiliate Member:
Please Select
1st year 50% off $52.50
MD $105
Student Member:
Enrolled in Psychology or Counseling Program
Please Select
1st year FREE
Student $30
Please complete
additional information:
Graduate School/Program:
Professional Activities:
Please Select
Psychotherapy
Psych Assessment
Teaching
Research
Professional Settings:
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Private Practice
Academic
Out-Pt Clinic
Hospital
Psychiatric
Please select all that apply:
Licensed Psychologist
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No
Registered Psychologist
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Yes
No
LMFC
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Yes
No
Psychological Assistant
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Yes
No
LCSW
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Yes
No
Licensed Psychiatrist
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Yes
No
MFT Trainee
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Yes
No
MSW Trainee
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Yes
No
Topics You'd Like to Hear About at SGVPA Functions:
Are you a member of:
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APA
CPA
National Registry
For multiple selections, press Crtl + select
Are you a Diplomat:
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Membership Directory Information:
Professional Settings :
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Private Practice
Academic
Out Patient Clinic
Hospital
Other
Professional Expertise/Specialties:
Testing Services:
Client Age Range:
Other Languages:
Type of Referrals Accepted:
Types of Funding Accepted:
(Medicare, Managed Care Panels, etc)
Please select committees of interest:
Committees in red type have an immediate need for new members.
Book Group
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No
Colleague Assistance
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Continuing Education
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Consultation
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Yes
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Disaster Response
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Yes
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Governmental Affairs
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Yes
No
Prelicensed or Early Career Professional
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Yes
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Programs
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Movie Night
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Ethics Committee
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Website Management
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Newsletter
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Membership
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Membership Directory Information:
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Academic
Out Patient Clinic
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My Directory Preferences:
Include the following information in the online
and printed Member Directory:
Include me in Member Directory
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Directory Choice
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Online
Print
Both
Publish my Address
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No
Publish my Phone Number
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Yes
No
Publish my Email
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Yes
No
Contact me for volunteer and/or SGVPA Committees
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Yes
No
Send all checks, made payable to SGVPA:
Attn: Stephanie Law, Psy.D. ,
SGVPA Membership Chair
Rose City Center
595 E Colorado Blvd, Suite 303
Pasadena, CA 91101
Individuals and/or professional
organizations occasionally request SGVPA’s membership
roster for the purpose of mailing announcements regarding
seminars, conferences, newsletters, etc. Please note that
by filling out this form your name and address may be made
available to the professional public.
***SGVPA is a chapter of CPA***