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: March to September 2008
_____ Professional
$25.00
|
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
$25.00
|
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
$12.50
|
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.