Section VIII, Couple and Family Therapy and Psychoanalysis,
Division 39, APA – Membership Application, 2015
Name:___________________________________________________ Degree: _________
Date:______________ Email Address:__________________________________________
Are you a member of Division 39, American Psychological Association? ___________
Home Address:__________________________________________________________________________
City:____________________________________ State:______ Zip:_________ Phone____________________
Include home address in Section VIII directory? Yes___ No___
Office Address #1: ___________________________________________ _____________________________________
City:_____________________________________ State:_____ Zip:__________Phone:___________________
Fax:_______________________
Office Address #2: ____________________________________________________________________________
City:_____________________________________ State:_____ Zip: _________Phone:____________________
Clinical/Research Interests (in order of importance) (NOTE: For the Membership Directory)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Areas of Practice Specialization (in order of importance): (NOTE: For the Membership Directory)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
DUES
Member $35 ____ Student $10 _____
PAY BY CHECK____________
APA Life Member $10 ______
Make check out to “Section VIII, Div. 39, APA”
PAY BY CREDIT CARD______ Amount $______
Circle One: MC
VISA Am Exp
Number ______________________________________ Exp. Date _________
Billing Address____________________________________________________
Signature: _______________________________________________________
Send form, with check or credit card information, to Lee Futrovksy, Ph.D., Treasurer, Sec.
VIII, 5454 Wisconsin Ave., Suite 1214, Chevy Chase, MD 20815
For more information, contact Cindy Baum-Baicker, cbbaicker@gmail.com