MEMBERSHIP APPLICATION

(Please check one:) NEW ____ RENEWAL ____

First Name:_______________________________________

Last Name:_____________________________________________

(Please check one:) Dr. ____ Mr. ____ Mrs. ____ Ms. ____

Address: _________________________________________

_________________________________________________

_________________________________________________

Telephone: (______)__________________________

Fax: (______)________________________________

Email Address: __________________________@_______________________
Will not be shared outside NARTH.

FOR PROFESSIONALS:

Academic Degree and Licensure:______________________

________________________________________________

Area of Specialization:_______________________________

Psychoanalytic, Psychiatric, or Social Work organization
of which you are a member:

_______________________________________________

BENEFITS OF MEMBERSHIP:

• All members (except students) receive our NARTH Bulletin, a three-times a year publication which describes the developments on the issue of homosexuality, including legal, social, and ethical issues; the latest scientific research, book reviews, challenges from the psychotherapeutic professional organizations; and in-depth interviews with psychotherapists.


• Qualified licensed psychotherapists may join our nationwide referral list.


• Students receive monthly e-mail updates. Please request a Student Membership brochure for details on our internet chat room, NARTH Bulletin available online and mentorship by clinicians.

______ Clinical: This category is intended for those individuals engaged in the psychological treatment and research of homosexuality. Membership is open to psychoanalysts, psychiatrists, psychologists, and certified social workers. Also included in this group are those who have completed master's-level training in sexuality or marriage and family life programs. Membership Fee: $65.

______ Research/Academic: This category of membership includes educators, public health officials, religious leaders, social scientists and historians, as well as writers in the field of sexuality and family health. This group is for professionals not conducting psychotherapy for homosexuality. Membership Fee: $65.

______ General: This group consists of all other individuals who wish to encourage the educational and therapeutic aims of this organization, and who want to be kept apprised of the work in progress. Membership Fee: $65.

______ Student: For full-time social science students. Proof of student status required--copy of student ID card or letter from school. Must provide email address. Fee: $10.

___ Please send me a Student Membership brochure for details on additional benefits of student membership.

Only U.S. funds accepted. If you live outside of the United States, you will receive NARTH reports and the NARTH Bulletin via email.

NOTE: If you are joining under the CLINICAL category, are you qualified to receive client referrals? You must be a licensed psychotherapist, in good standing in your professional organization, with experience in the sexual reorientation treatment of homosexuals. If you wish to receive an application, check here: ___ .

FILL OUT INFORMATION BELOW COMPLETELY:

Enclosed is my check, payable to NARTH for __________________ .

_______________________________________________
Credit Card Number (Visa or Master Card only)

_______________________________________________
Three-number Security Code (from back of credit card)

_______________________________________________
Credit Card Expiration Date

SEND APPLICATION TO:

NARTH
307 West 200 South, Suite 3001
Salt Lake City, UT 84101
1-888-364-4744
Email: info@narth.com


Donations to NARTH are tax deductible.