Seattle Counselors Association
Membership Application
Complete both pages, sign & mail it with your check to:
Seattle Counselors Association, PO Box 58530, Seattle WA 98138
206-283-1888

Check one type:                       Renewal                    New Member

Check one membership category: Professional $85.00     Student $42.50
                                             Retired $42.50            Agency/Institution $115.00
        Pays for newsletter, website listing, directory, general SCA operating costs.

Option to Prepay Meetings for Entire Year                        $170 (Save $30)
Meeting fees are separate from membership fees. Paid individually, the cost for members is $20 per meeting (+ $40 in June), or $200/year. This discount is available through the September meeting ONLY.

First Name _______________________ Last Name __________________________

Mailing Address _______________________________________________________

City _____________________ State _____ ZIP ________ Highest Degree _______

Do you have a private practice? Yes No

Practice Name ____________________ Agency Name ________________________

Practice Phone (____) _____________ Agency Phone (____) __________________

Fax Number     (____) _____________ Email Address _________________________

Home Phone    (____) _____________ Website Address _______________________

Would you like to receive the newsletter by email? Yes No

Description of Practice for directory and website (issues with which you commonly help clients, therapeutic approaches, how you work, etc.)  Limited to 50 words 
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Professional License or Registration in the State of Washington:
Type(s) __________________________ Number(s) __________________________
    (e.g., LMFT, LICSW, LMHC, PhD, RC)
RELEASE: I grant permission to release this information to other SCA members in the annual SCA membership directory, and to have this same information listed in the directory on SCA’s website.            Yes     No
        Home phone numbers are NOT listed on the website or directory.
      

Signature __________________________________ Date ______________________
*** More information requested on the next page! [below]***

Please check all the boxes that are relevant to your practice.

CLIENT POPULATIONS                            SESSION TYPES

Adults           Elderly Adolescents   Men Children         Women

Individual    Groups Couples       Workshops Families

CLINICAL SPECIALTIES -- Limited to 10, please.
Focus on your areas of specialization.

Abortion Abuse – Emotional, Sexual, Physical Adolescence & Parents:        Separation/Individuation Adoption/Foster Care Aging Anger/Conflict Management Anxiety/Panic Disorders Art Therapy Attention Deficit Disorder Bipolar Disorder Body Image Body Psychology Career Counseling Caregiver Concerns Case Management Computer/Internet Addiction Couples Counseling Crisis Counseling Death & Dying Depression Divorce Domestic Violence Dual Diagnosis Eating Disorders EMDR Gay/Lesbian/Bisexual Gender Identity Grief & Loss Hypnosis Infertility Life Coaching Life Goals Life Transitions

Mediation Medical Illness/Conditions Medications Men’s Issues Movement Therapy Multicultural Issues Music Therapy Obsessive/Compulsive Disorder Pain Control Parenting Personality Disorders Personal Growth Phobias Physical Abuse Post Traumatic Stress Disorder Practice Development Pregnancy Prenatal/Perinatal Psychology Psychodrama Psychospiritual Growth Recreation Therapy Relationship Issues Schizophrenia Separation & Individuation Sexual Compulsion/Addiction Sexual Harassment Sexuality Social Skills Spirituality Stepfamily/Blended Family Stress Management Substance Abuse/Addiction Transgender Women’s Issues Workplace Issues