Membership Application Select Your Membership LevelLevel 1: Mental Health and Performance Service Provider$150.00Level 2: Mental Health Provider$150.00Level 3: Professional in Training$50.00Affiliate Status$100.00Select Your Payment CycleAnnuallyEvery 2 YearsSelect Your Payment CycleAnnuallyEvery 2 YearsSelect Your Payment CycleAnnuallySelect Your Payment CycleAnnuallyMembership ApplicationMember Information * Username * PasswordStrength: Very Weak Salutation * First Name Middle Initial * Last Name * Email Address Mobile PhoneProfessional Practice / Primary Address Professional Practice Occupation/TitleCountry/RegionCountry/RegionAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongoCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country/Region * Address 1 Address 2 * City* StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming * State * Zip Code Phone Fax WebsiteProfessional Experience * Current Employer * Current Job Title * With what institution do you have affliation?* In what capacity do you provide services?Sole ProviderConsultantContracted ProviderIn-House ProviderOther * In what capacity do you provide services?* Preferred Means of ContactOffice PhoneCell PhoneEmail * Preferred Means of Contact* How long have you been in your current position?Less than 1 month1-6 months1-3 yearsOver 3 years * How long have you been in your current position?* Primary Sport Clientele CategoryCollegiate SportProfessional SportOlympic/Paralympic/National SportNon-Sport Performer * Primary Sport Clientele Category * Mental Health Discipline (e.g. Psychology, Social Work, Counseling, etc.): * Please provide a brief statement regarding your training in sport & performance psychology. * Primary State / Province of Licensure * Licensure Number* Proof of LicensureDone(Use Cropper to set image and use mouse scroller for zoom image.)Done(Use Cropper to set image and use mouse scroller for zoom image.)Drop file here or click to select.* Do you hold a provisional license with your state/provincial board that requires on-going supervision to practice? YesNoNote: In order to be approved at Level 1 or 2, you must be fully licensed within the next calendar year and send updated documentation at that time. Additional CommentsMembership Directory Would you like to be included in the membership directory?YesNoIf would like to be included in the directory, please provide the information below. This information will be displayed alongside your practice details in the directory. Display Name Credentials State(s) of Licensure Team or Department Affiliation LocationAccepts Private Clients?YesNo Accepts Insurance? If so, which insurance?Psypact Member?YesNoMode of TherapyIn Person OnlyTelehealth OnlyEither In Person or Telehealth Mode of Therapy Specialty areas/trainingMembership Attachments Professional Headshot (Required)Drop file here or click to select.Please upload a current, high-resolution professional headshot.Resume/CV (Optional)Drop file here or click to select.Please upload a recent resume/CV if there has been significant changes to your training or work experience.Level 3 Supervision Drop file here or click to select.The Level 3 applicant must provide a letter from a current licensed professional providing sport psychology and mental health services to athletes stating that the professional in training is in formal training under that professional’s supervision in order to obtain a job in the future with elite athletes. Payment MethodPaypalPay by CheckPlease mail checks to the following address: Tess Palmateer 10580 SE Innovation Way Apt 203 Port St. Lucie, FL 34987Account Holder NameAccount Holder NamePlease enter Account Holder Name.Additional Info/NoteAdditional Info/NotePlease enter Additional Info/Note.How would you like to pay?Auto Debit PaymentManual PaymentHave a coupon code?ApplyPayment SummaryYour currently selected plan: Plan Amount: (annually) Final Payable Amount: SubmitAlready have an account? Login