Membership Application

Clinical Level

For fastest service, we encourage online payment. It's fast and secure. If you do need to pay by check, do not complete the form below. Request an invoice instead.

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First Name *

Last Name *

Company or Organization Name *

Email *

Always use the SAME email address when you make purchases with LPCA. This ensures that all activity is properly credited to the same account.

Mobile Phone *

Address

Street Address *

City *

State *

Country

Postal Code *

Choose single year or auto-renew, then enter payment details *

Membership: Clinical (Auto-Renew)

Subscription

$150

Membership: Clinical (One Year)

$150

Would you like to be published in the public directory?

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Directory Street Address

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Job Title

Therapy Provided *

Accept Insurance *

Yes

No

Setting *

Service Provided *

Population Served *

Ages Served *

County Served (Choose All That Apply) *

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