Please print
out and
complete the
following
information*:
PCCA
Membership
Application
Form
Pierce
County
Counselors
Association
Name:
____________________________________________________________
Licensure or
registration
type:__________________________________________
Business
Name (if
applicable):
_________________________________________
Business
Address:
__________________________________________________
City:______________________________
WA. (zip
code)____________________
Home
Address:
_____________________________________________________
City:______________________________
WA. (zip
code)____________________
Business
Phone:
____________________
Home Phone:
___________________
Cell Phone:
_______________________________
Email:
___________________________________
(please
repeat)
Email:
___________________________________
Please check
the
appropriate
Membership
Category,
below.
Membership:
October
2008 to
September
2009
|
_____
Professional
$60.00 |
Any
mental
health
professional,
including
professional
counselors,
social
workers,
psychologists,
psychiatrists,
psychiatric
nurses,
and
marriage
and
family
therapists
who
are
licensed
in
any
state
may
become
a
professional
member
of
PCCA.
These
licensed
professionals
must
have
a
Master’s
degree
or
higher
in a
field
of
mental
health. |
|
_____
Associate
$60.00 |
Any
registered
counselor
in
the
state
of
Washington;
any
state
qualified,
chemical
dependency
counselor;
or
any
professional
who
works
in
an
activity,
program
or
business
related
to
mental
health
may
become
an
associate
member
of
PCCA. |
|
_____
Student/Retired
$30.00 |
Any
graduate
student
pursuing
a
Master’s
degree
or
higher
in
any
field
of
mental
health
and
any
retired
mental
health
professional
may
become
a
student
member
of
PCCA. |
Mail this
form,
together
with your
check to the
address
below
[or present
this form to
the
registrar at
a meeting].
MAILING
ADDRESS:
PCCA, c/o
Phil
Prudhomme,
3315 S 19th
Street,
Tacoma, WA
98405
* Your
information
will only be
used for
PCCA
business and
will not be
shared.
