Membership Application

Membership Level: First Name: Last Name: Email: Phone: Home Mobile Other Work Address Type: Home Work School Other Address: Address Line 2 City: County: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Business Name: Job Title: Are you a provider of color? Yes No Do you provide services in a language other than English? Please check all boxes that apply: Newsletter Subscriptions Are you interested in learning more about volunteer opportunities with PS-WA? (Opportunities include: facilitating postpartum support groups, Warm Line support, and administrative support tasks.) Yes No Please list your credentials (LMHC, ARNP, etc): How long have you been in practice? How long have you worked with pregnant families and families with perinatal mood and anxiety disorders (PMADs)? Do you meet the following criteria? Have you completed two or more of the following? Please share your contributions/training/community enagagement in the field of perinatal mental health. (i.e do you offer training, supervision, participate in community initiatives, volunteer services, etc). What trainings about perinatal mood and anxiety disorders have you attended (in person or web-format)? Please provide name of organization, dates of training and name of trainer(s) wherever possible. What is your experience treating parents with perinatal mood and anxiety disorders? If you prescribe medications, please indicate your knowledge of: (Please note: If you have received specialized training in medication management of pregnant and breastfeeding parents, please include that training in the question above.) Requirements to remain on our provider lists (By checking the box you agree to the following):