New York Mental Health
Counselors Association


New Member Sign Up Form

This is required information for a NYMHCA membership.

After completing this form, you will be directed to ProfessionalCharges.com.  NYMHCA uses the secure payment processing services of ProfessionalCharges.com to handle online credit and debit transactions. If you do not wish to pay by credit or debit card online, please contact NYMHCA via email at NYMHCA2@optonline.net, or call us at: 1-800-4-NYMHCA. You may also click here to view a printer friendly version of the online registration form or download a PDF version. Instructions for submission by check are on the form.  

Membership Categories
   
Professional:  Masters degree or higher in counseling or a related field that covers the basic principles of mental health counseling. Degree is from a regionally accredited institution of higher learning. (Able to vote and hold certain offices)
   
Student: Enrolled at least half time in a graduate program in counseling or related discipline. Not yet licensure eligible. (Able to vote and hold certain offices)
   
Retired:  Masters degree or higher in counseling or related field that covers the basic principles of mental health counseling. Degree is from a regionally accredited institution of higher learning. (Able to vote and hold certain offices)
   
Associate:  Primary work responsibilities are in human resources/personnel. Also eligible are undergraduate students who intend to pursue a Master's in mental health counseling or related clinical field. (Not able to vote or hold certain offices)
 
For a list of offices that members can run for, please contact our office.
 
*NOTE: Fields in Red are Required

Membership Type:

$120.00
$60.00
$60.00
$45.00

If you are a student,
please include your College/University:
If you are a student,
please include your major: 
NYMHCA members are invited to join their local NYMHCA chapter (or chapters)
at the same time they join NYMHCA.  The chapters are:

 

Chapter membership is not mandatory.
        


Buffalo/Niagara Chapter
Capital Region Chapter
Central Region Chapter
Hudson Valley Chapter
Long Island Chapter
Metro - NY Chapter
Rochester Chapter
Rockland Region Chapter
Staten Island Chapter
Westchester Chapter
Do not include in the local chapter

         
      Title First Name Middle Last Name  
    
   
Home Address (Include Apt/Suite #):
Home City:
Home State:
Home Zip:
Home Phone Number: 
(xxx) xxx-xxxx
If your private practice address is the same as your home address, please
fill out both company and home address categories.
Company Name:
Business Address:
(Include Apt/Suite #) 

Business City:
Business State:
Business Zip:
Business County:
Business Phone Number: 
(xxx) xxx-xxxx
Business Fax Number: 
(xxx) xxx-xxxx
Primary Email Address: 
Secondary Email Address: 
Newsletter Preference
  
Birthdate: 
mm/dd/yyyy
Marital Status: 





   
Practice Opening Date: 
Degrees Completed: 
Training:
Credentials: 
Other Associations Memberships:

Type of License or Certification held: 
(enter N/A if not applicable)
(LMHC, LMFT, LMSW, etc.)
State of License: 
(choose N/A if not applicable)
n/a
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
   
Would you like a Membership Certificate suitable for framing?
The cost is an additional $20:
Please print your name exactly as you would like
for it to appear on your Membership Certificate:
   
Check any Committees
you would like to join:
(please join no more than 3 committees) 

Professional Development
Governmental Relations
Ethics/Bylaws
Public Awareness
Nominations and Elections
Convention Planning
Strategic Planning
Diversity
Fund Raising
Student Development

Any other activities or expertise you would like to
contribute to NYMHCA: 
Would you like information regarding becoming a 
participant in our Speaker's Bureau?: 
(Speakers Bureau materials will be sent to you by
mail with membership material)
 
   
Donation to ongoing Legislative Efforts:
 $  
Donation to Student Scholarship Fund:
 $  
Allow us to decide where to
apply your donation:

Dues or donations paid to NYMHCA are not tax deductible.
   
Please choose a Personal Password for access to our
Members Only page and your personal record:
   
How did you learn about
this organization? 
Email Notice
Saw Ad
Phone Contact
Letter
From a Colleague
National Association Newsletter
State Association Newsletter
Postcard
Website
Conference
Other
 
Please send me NYMHCA
membership material
for a colleague: 
Number of copies

The Find A Counselor Directory

A Basic Listing is free - and part of your NYMHCA membership. An Expanded Listing will tell potential clients more about you and the services that you offer, including listing your web site address or email address if you desire.  An Expanded Listing is only $35 per year (or $65 per year with the Find A Supervisor listing).
Would you like to be listed on the Find-A-Counselor Directory?: 
If you choose "YES", your contact information will be accessible to visitors who are looking for a therapist on the NYMHCA.org web site.  If you choose "NO", then none of your information will be accessible to visitors who may be looking for a therapist.
If you chose "YES" to be listed on the Find-A-Counselor directory, choose a type of listing:
  
view a basic listing
view
 an expanded listing.
Specialties: 
ADD/ADHD
Addictions
Adoption
Adjustment Disorders
After Death Care / Funeral
Alcohol Abuse / Dependence
Anxiety Disorders
Biofeedback
BiPolar / Mania
Child Abuse
Corporate Training
Counseling/Psychotherapy
Couples Counseling
Death Education and Training
Death / Dying / Bereavement
Depression
Diagnostic Evaluations
Disabilities
Domestic Violence
EAP - Employee Assistance
Eating Disorders
EMDR
Family Counseling
Gay / Lesbian, Bisexual and Transgender Issues
Grief and Loss
Hospice
Hypnosis
Infertility
Intern Supervision
Marriage Counseling
Mediation
Medication evaluations
Mens Issues
Mental Health Education and Training
Neurofeedback
Neurological Disorders
Personal Coaching
Personality Disorders
Pet Loss
Philosophical Counseling
Play Therapy
Pre-Marital
Psychological Disorders
Relationships
Schizophrenia
Sexual Disorders
Sexual Abuse
Substance Abuse/Dependence
Spirituality
Stress
Veterans Issues / PTSD
Volunteer Training
Womens Issues

Find-A-Counselor Directory Expanded Listing Information 

This is for all Expanded Listings.  You need only to complete this if you are purchasing the expanded listings. 
You do NOT need to complete this section if you are not listed on the Find A Counselor Directory or
you have a Basic - Free Listing on the Find A Counselor Directory.
Second Office Address:
Second Office City:
Second Office State:
Second Office ZIP:
Second Office Phone Number
How to schedule an appointment:
Email Address:
only one address
(If you do not want your email address listed in the Find A Counselor Directory, leave this blank)
Your Web Page Address:
 http://
Education: 
(graduate and post graduate)
Your Gender:
Type of Therapy conducted:
Individual
Couple
Family
Group
Philosophy -
Please write a brief paragraph describing the services
you offer and the population you serve:
Years in Practice:
Do you have any special insights for clients
of the following ethnicities:
African American
Asian
Latino
Native American
Pacific Islander
Bi-racial
Other
Other Ethnic Insights:
Please list all languages spoken fluently:
Average Charge Per Session: 
Type of Payment Accepted:
Check
Cash
Charge
Insurance
Insurance accepted:
Type of Insurance accepted:

The Find A Clinical
Supervisor Directory

This directory is for those looking for a Supervisor.  This service is $35 per year or $65 per year if you also select the Expanded Listing on the Find A Counselor Directory.  
Would you like to be listed as a Clinical Supervisor?:
Educational Affiliation:

Average Charge Per
Supervisor Session: 
Please write a brief statement about your
Philosophy of Clinical Supervision:
 
After you click the Join button, your registration may take a few seconds and then you will see a page that says New Record Added and give you your password.  You will have successfully completed the registration process and can check your listing immediately on the directory.