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.

 

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