Family Systems Therapists Northwest
Membership Application
_____________________________________
First name
______________________________________
Last name
_____________________________
Preferred nickname (if applicable)
_______________________________________________________________________________________________________________
Mailing address
___________________________________________
City/State
________________________________
ZIP code
_______________________________________________________
Email
_____________________________
County
____________________________________________________
Phone
_______________________________________________________________________________
Website
Credentials
_______________________________________________________
Highest Mental Health Degree Earned
____________________________________________________
Alma Mater
Mental Health Credential(s):
__ LMFT
__
LMHC
__ LASW
__
LICSW
__ LMFTA
__
LMHCA
__ LASWA
__
LICSWA
__ Psychologist
__
Retired
__ Student
Other: _______________________________________________________________________
DOH License Number(s):
LMFT or LMFTA: ______________________________________________________________
LMHC or LMHCA: _____________________________________________________________
Social Worker: ________________________________________________________________
Other: _______________________________________________________________________
Practice Information
Populations Treated:
__ Adults
__
Children
__ Geriatric
__
Adolescents
__
Family
__ Group
__
Couple
__
Bipolar
__ Dissociative disorders
__
Parenting
__ Addiction/compulsive disorder __
Body image/eating disorders
__ Divorce
__
Personality disorders
__ Anxiety
__
Couples issues
__ Gender identification
__
PTSD
__ Attachment disorder
__
Cross-cultural
__ LGBTQ
__
Sexual disorders
__ Autism spectrum disorder
__
Depression
__ OCD
Modalities Used:
__ Individual
Treatment areas:
__ ADD
Approaches:
__ Attachment therapy
__
Energy Psychology
__ Jungian psychotherapy
__
Psychodynamic therapy
__ CBT
__
Family Constellations
__ Mindfulness
__
Sex therapy
__ EMDR
__
Gestalt therapy
__ Narrative therapy
__
Solution-focused
__ EFT (Emotionally Focused
__
Hypnotherapy
__ Play therapy
__
Structural/strategic
__
IFS
__ Psychoanalysis
__ Private practice
__
Medical
__ School
__
Author/presenter/consultant
__ Nonprofit
__
Public health
__ College/university
Therapy)
Mental health settings:
Other: _______________________________________________________________________
Member Connections
Member-only directory: As a FSTNW member, you will have access to a directory of other members for the purpose of networking, referrals,
and community-building. You will be automatically included in this directory unless you opt-out by checking this box.
__ Please check here if you would like to be EXCLUDED from this directory.
Public Referral directory: As a FSTNW member, you can be listed on a directory which the public can use to find a clinician.
__ Yes, include me on the public directory.
__ No, don’t include me.
eContact: Your FSTNW membership includes an eNewsletter as well as emails featuring updates and early bird discounts to FSTNW events.
__ Yes, include me. (FSTNW will never sell or rent your contact information.)
__ No, don’t include me.
Listserv: Your FSTNW membership includes membership in the FSTNW listserv.
__ Yes, add me to the listserv. (FSTNW will never sell or rent your contact information.)
__ No, don’t add me.
Contact me about volunteer opportunities:
__ FSTNW leadership
__
__ Networking/social event host __
Event assistance
__ Social media
__
Advocacy
Finding practice resources
__ Writing for e-news
__
Third-party payer
Directories
If you are opting in to be listed in the public Referral directory, please complete the information below. You can also complete this section if you
would like to share your office information on the Member-to-Member directory.
Practice Description (This area can be used to provide a brief description of your practice, which will be published in both directories. You can
also name modalities, issues treated, etc., not listed elsewhere which would be helpful in a keyword search by potential clients.)
Do you accept insurance? (No need to list panels, just confirm whether you accept insurance) ___ Yes ___ No
Office Information: ___ Same as listed on page one (please list neighborhood below). If different, please complete the following:
Street Address: _____________________________________________________________________________________________________
__________________________________________________________________________________________________________________
City: _________________________ St./Prov./Region: ______________
Zip/Postal code: ______________ Country: ________________
Office neighborhood: ___________________________________ Telephone: __________________________________________________
Membership Levels and Benefits
All members enjoy Basic Member Benefits, including:






Reduced registration rates at events
Listserv to share ideas and referrals
Listing in FSTNW’s public referral directory to help potential clients find your practice (licensed members only)
Listing in FSTNW’s member-to-member directory to build your practice community
Subscription to The Pulse magazine with practice-building articles written by community members
Quarterly payment options, automatically renewed annually, for your convenience
You can join at the Clinician, New Clinician (student/associate-licensed) or Senior Clinician (age 60+ or retired) levels. If you
want to make a more substantial investment in your professional association, we hope you will consider joining at one of our two
special membership levels:


The Leadership Circle is a special two-year membership. It is designed to help FSTNW grow, and will give you a
permanent place as a leader of your local professional home.
Sustaining Members make an ongoing commitment to helping FSTNW enrich our profession.
In addition to the Basic Member Benefits listed above, these membership levels have added benefits, including:
Leadership Circle - $300/year; two-year membership – Available to all license levels
 Listing as a Leadership Circle member on our website and publications
 Honoring at select FSTNW events
 May bring a non-member guest to any FSTNW Salon Event at no charge
 Clinician, Senior Clinician, or New Clinician benefits as appropriate
Sustaining Member - $150/year – Available to all license levels
 Listing as a Sustaining Member on our website and publications
 Honoring at select FSTNW events
 Clinician, Senior Clinician, or New Clinician benefits as appropriate
Clinician - $80/year – Available to fully-licensed clinicians
 Listing on supervisor database
 Free advertising: website classifieds; e-newsletter classifieds
 We hope to make available in the future: reduced rates for professional liability insurance
Senior Clinician - $50/year – Available to clinicians age 60+ or retired
 Clinical Member Benefits at a reduced membership fee
New Clinician - $50/year – Available to students or associate-level clinicians
 Eligible for scholarships/professional development grants
Choose Membership Level
_____
Leadership Circle - $300/year; two-year membership
_____
Sustaining Member - $150/year
_____
Clinician - $80/year
_____
Senior Clinician - $50/year
_____
New Clinician - $50/year
Referred by: ____________________________________________________________________________________________________
If you were referred by a FSTNW member, let us know and we will give them $10 off their member renewal.)
Payment Information
You can pay your membership dues in one payment or quarterly payments (Sustaining Members pay in quarterly payments only).
_____
I am making my entire annual membership payment (pay by check or credit card)
_____
I would like to pay for my membership in quarterly payments (pay by credit card only, automatically renewed)
Payment Method
_____ Check: payable to “FSTNW” (annual payment only)
_____ Visa
_____
MasterCard
_____ AMEX
Name on card: ______________________________________________
Card #: ____________________________________________________
CVC Code: ________________
Expiration date: _____________________________________________
Please return this form with payment to: FSTNW, 1229 Cornwall Ave, Ste 308, Bellingham, WA 98225, or fax it 360-230-3294.
Revised 11/23/16
Approaches:
__ Attachment therapy
__
Energy Psychology
__ Jungian psychotherapy
__
Psychodynamic therapy
__ CBT
__
Family Constellations
__ Mindfulness
__
Sex therapy
__ EMDR
__
Gestalt therapy
__ Narrative therapy
__
Solution-focused
__ EFT (Emotionally Focused
__
Hypnotherapy
__ Play therapy
__
Structural/strategic
__
IFS
__ Psychoanalysis
__ Private practice
__
Medical
__ School
__
Author/presenter/consultant
__ Nonprofit
__
Public health
__ College/university
Therapy)
Mental health settings:
Other: _______________________________________________________________________
Member Connections
Member-only directory: As a FSTNW member, you will have access to a directory of other members for the purpose of networking, referrals,
and community-building. You will be automatically included in this directory unless you opt-out by checking this box.
__ Please check here if you would like to be EXCLUDED from this directory.
Public Referral directory: As a FSTNW member, you can be listed on a directory which the public can use to find a clinician.
__ Yes, include me on the public directory.
__ No, don’t include me.
eContact: Your FSTNW membership includes an eNewsletter as well as emails featuring updates and early bird discounts to FSTNW events.
__ Yes, include me. (FSTNW will never sell or rent your contact information.)
__ No, don’t include me.
Listserv: Your FSTNW membership includes membership in the FSTNW listserv launching later this month (May 2016).
__ Yes, add me to the listserv. (FSTNW will never sell or rent your contact information.)
__ No, don’t add me.
Contact me about volunteer opportunities:
__ FSTNW leadership
__
__ Networking/social event host __
Event assistance
__ Social media
__
Advocacy
Finding practice resources
__ Writing for e-news
__
Third-party payer
Membership Levels and Benefits
All members enjoy Basic Member Benefits, including:






Reduced registration rates at events
Listserv to share ideas and referrals
Listing in FSTNW’s public referral directory to help potential clients find your practice (licensed members only)
Listing in FSTNW’s member-to-member directory to build your practice community
Subscription to The Pulse magazine with practice-building articles written by community members
Quarterly payment options, automatically renewed annually, for your convenience
You can join at the Clinician, New Clinician (student/associate-licensed) or Senior Clinician (age 60+ or retired) levels. If you want to make a
more substantial investment in your professional association, we hope you will consider joining at one of our two special membership levels:


The Leadership Circle is a special two-year membership. It is designed to help FSTNW grow, and will give you a permanent place
as a leader of your local professional home.
Sustaining Members make an ongoing commitment to helping FSTNW enrich our profession.
In addition to the Basic Member Benefits listed above, these membership levels have added benefits, including:
Leadership Circle - $300/year; two-year membership – Available to all license levels
 Listing as a Leadership Circle member on our website and publications
 Honoring at select FSTNW events
 May bring a non-member guest to any FSTNW Salon Event at no charge
 Clinician, Senior Clinician, or New Clinician benefits as appropriate
Sustaining Member - $150/year – Available to all license levels
 Listing as a Sustaining Member on our website and publications
 Honoring at select FSTNW events
 Clinician, Senior Clinician, or New Clinician benefits as appropriate
Clinician - $80/year – Available to fully-licensed clinicians
 Listing on supervisor database
 Free advertising: website classifieds; e-newsletter classifieds
 We hope to make available in the future: reduced rates for professional liability insurance
Senior Clinician - $50/year – Available to clinicians age 60+ or retired
 Clinical Member Benefits at a reduced membership fee
New Clinician - $50/year – Available to students or associate-level clinicians
 Eligible for scholarships/professional development grants
Choose Membership Level
_____
Leadership Circle - $300/year; two-year membership
_____
Sustaining Member - $150/year
_____
Clinician - $80/year
_____
Senior Clinician - $50/year
_____
New Clinician - $50/year
Referred by: ____________________________________________________________________________________________________
If you were referred by a FSTNW member, let us know and we will give them $10 off their member renewal.)
Payment Information
You can pay your membership dues in one payment or quarterly payments (Sustaining Members pay in quarterly payments only).
_____
I am making my entire annual membership payment (pay by check or credit card)
_____
I would like to pay for my membership in quarterly payments (pay by credit card only, automatically renewed)
Payment Method
_____ Check: payable to “FSTNW” (annual payment only)
_____ Visa
_____
MasterCard
_____ AMEX
Name on card: ______________________________________________
Card #: ____________________________________________________
CVC Code: ________________
Expiration date: _____________________________________________
Please return this form with payment to: FSTNW, 1229 Cornwall Ave, Ste 308, Bellingham, WA 98225, or fax it 360-230-3294.
Revised 11/23/16