Name Your name is required
Email Your Email is required
Make email public? Yes No
Website
Make website public? Yes No
Office Phone Office Fax
Office Address Office Street Your Street is required Suite/Apt. # City Your city is required State Your state is required Zip Code Your zip is required
Are you presently licensed by TSBEP? No Yes Please select
Are you presently certified by TSBEP? No Yes Please select Please select
Are you a current member of TPA? Yes No
Are you a current member of APA? Yes No
Are you applying for a new membership or renewal? Renewal Membership New Membership Select Please select Please select
PLEASE INDICATE BELOW MEMBERSHIP LEVEL FOR WHICH YOU ARE APPLYING
Member $50 (Voting Member) “Members of this Association must be at least one of the following: Doctoral level psychologists who are currently licensed by TSBEP, Doctoral level psychologists who have retired their license in good standing from the appropriate state licensing board, Fellow or doctoral level member of the American Psychological Association or the Texas Psychological Association.” Check all that apply.
Please indicate your status Licensed Psychologist Provisionally Licensed Psychologist Licensed Specialist in School Psychology (Doctoral Degree) Retired Psychologist
Associate Member $50 (Non-Voting Member) “Associate members shall be persons who do not meet criteria for membership but have interest in the organization and are supportive of its purposes.” Please indicate your status Licensed Psychological Associate Licensed Specialist in School Psychology (masters degree) Other mental health professional Other
Student Affiliate Free (Non-Voting Member)
MEMBERSHIP ETHICS QUESTIONS - ALL QUESTIONS BELOW MUST BE ANSWERED
1.Has your license/certificate been suspended, revoked, or limited by a state licensing board in the past 12 months? No Yes
2. Have you been convicted of a felony during the past 12 months? No Yes
4. Have you been found guilty of malpractice during the past 12 months? professional organization or licensing board during the past 12 months? No Yes
PSYCH SELECT
FWAPA offers PsychSelect, a web-based referral service, for an additional $50.00 per year.
Would you like to be part of FWAPA's Psych Select Service? No Yes Please select Please select
Attention Problems/ADHD Anger Management Anxiety /Stress Biofeedback Bipolar/Schizophrenia Borderline Personality Career counseling/Testing Children’s Problems Child custody Depression Dissociative Disorders Eating Disorder/Weight Family Problems Gambling Gay/Lesbian Issues Grief Group Therapy Hypnosis Industrial/Consulting Learning Disability Marriage/Relationship Medical Problems/Pain Neuropsychology/Brain Injury Panic/Phobia Post Traumatic Stress R.E.T./Cognitive Therapy School Problems Sexual Problems Sign Language Sliding Scale Fee Smoking Cessation Spanish Speaking Spiritual Issues Substance Abuse/Alcohol Testing/Evaluation Worker’s compensation
Please list up to 10 insurance panels for which you provide service:
If you have any questions about the application or fees, please email fwapa@fwapa.org