New York Mental Health Counselors Association

New Member Sign Up Form

This is required information for a NYMHCA membership.
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)
New Professional:  Masters degree or higher recently conferred. Eligibility for one year only after graduation for current NYMHCA student members only.  (Able to vote and hold office)
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)
 
*NOTE: Fields in Bold are Required
Membership Type:

$120.00
$80.00 (one year only)
$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
at the same time they join NYMHCA.  The chapters are:

 

Chapter membership is not mandatory.
        

$25
$15

 











         
Title First Name Middle Last Name  
   
Home Address:
Home City:
Home State:
Home Zip:
Home Phone Number: 
(xxx) xxx-xxxx
   
Company Name:
Business Address:

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: 
Birthdate: 
Marital Status: 




   
Practice Opening Date: 
Degrees: 
Training and Credentials:
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)
   
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: 

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: 
$ Dues or donations paid to NYMHCA are not tax deductible.
   
Please choose a
Personal Password:
   
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
 
If you would like us to send
material for a colleague enter
their full name and address: 
 

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:
 

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
Other Associations Memberships:

 

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:

Print this form. Please make checks payable to NYMHCA. Mail both the registration form and payment to:

NYMHCA
206 Greenbelt Parkway
Holbrook, NY, 11741