Membership Application

Individual Membership

Prefix

First Name *

Middle Name

Last Name *

Suffix

Address

Street Address *

City *

State or Province *

Country *

Postal code *

Primary Email *

Alternate Email

Practice Group(s)

Primary Practice Group

Additional Practice Groups

Professional Public Directory

Do you want to be listed in our public professional directory? *

Yes

This is the address that will be included in the PUBLIC directory if you choose to be listed.
You must include the State/Province and Country fields if you wish to be included when directory users filter by those parameters.
If you do not wish to be visible in the public directory, you may leave the information below blank.

Office Street Address

Office City

Office State/Province

Office Postal Code

Business or Organization Name

Office Email

Office Phone

Office Country

Headshot (used for your Directory Profile)

We have found that members who include an image in their bio receive more views by potential clients.

Professional Information

LinkedIn Link

Facebook Link

Area(s) of Practice *

License(s) *

Website Link

Postgraduate Education

Professional Education

Education Information

Please enter information in the following format: Name of Institution, 4-digit-year

Example: Loyola Marymount, 1991

Undergraduate Education

Introduction / Very Brief Bio

Additional Details

Accommodations

Proficient in LGBT matters

Disabled-accessible office

Multilingual

ASL

Data Sharing

Data Sharing *

Yes

IACP occasionally makes its members' addresses (excluding telephone and email) available to other colleague organizations and to vendors who provide products and services to the Collaborative community. If you prefer not to be included in these lists, please select 'no'.

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Membership Dues

Sell Products *

Membership: Individual (Auto-Recurring)

Subscription

$209

Membership: Individual (One-Year)

$209