MEMBERSHIP APPLICATION
Please print out the following and mail it in to the address below. Or you can
download the form as a PDF or a Microsoft Word document.
(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.
CATEGORY OF MEMBERSHIP
Please check one:
______ 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
16633 Ventura Blvd., Suite 1340
Encino, CA 91436-1801
818-789-4440
Email: nationalarth@yahoo.com
Donations to NARTH are tax deductible.
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