Anxiety Disorders Association of America



lefttopAnxiety and Depression Association of AmericaProfessional Membership ApplicationApply online at or send this completed application toADAA 8701 Georgia Ave., Suite 412 Silver Spring, MD 20910 Fax 240-485-1035 | Phone 240-485-1030 0000Contact information Name________________________________________________________________________________________Degree(s) ___________________________Title_____________________________________________________Current institution/business_______________________________________________________________________Business address____________________________________________________________________________City_______________________State/Province___________________Zip Code_____________Country_______Phone _____________________________________________ Cell phone ________________________________Email address______________________________________ Include in your online practice profile? FORMCHECKBOX Yes FORMCHECKBOX NoDo you want your practice profile listed in the ADAA Find a Therapist online directory? FORMCHECKBOX Yes FORMCHECKBOX NoI am a (check all that apply) FORMCHECKBOX Clinician FORMCHECKBOX Researcher FORMCHECKBOX Researcher/Clinician FORMCHECKBOX Other (please specify) ________________________________________________________________________Preferred mailing address (if different from above) _____________________________________________________________________________________________My Practice Profile (What you want clients to know about you and your practice)__________________________________________________________________________________________________________________________________________________________________________________________Enhance my Find a Therapist listing: FORMCHECKBOX One additional practice address ($40)Address _______________________________________________________________________________City/State/Zip/Country ____________________________________________________________________ FORMCHECKBOX Link to your website ($55) published on your online listing.URL __________________________________________________________________________________Fees PaymentAnnual dues . . . . . . . . . . . . . . . . . . . . . . $229_ FORMCHECKBOX CheckAdditional office address ($40) . . . . . . . . _____ FORMCHECKBOX Visa FORMCHECKBOX MasterCardWebsite link ($55) . . . . . . . . . . . . . . . . . _____Card number ________________________________________Donation to ADAA . . . . . . . . . . . . . . . . . _____Expires _______________________ Security code _________ Total amount due . . . . . . . $________Name on card ________________________________________Signature ____________________________________________ADAA Online Profile Years in practice 1371600-6286500Fewer than 5 FORMCHECKBOX 6 to 10 FORMCHECKBOX 11 to 15 FORMCHECKBOX 16 to 20 FORMCHECKBOX More than 20 FORMCHECKBOX PaymentsAccept credit cards FORMCHECKBOX Accept insurance FORMCHECKBOX Medicare FORMCHECKBOX Medicaid FORMCHECKBOX Sliding scale FORMCHECKBOX Treatment (check all that apply)Adolescents/Teens FORMCHECKBOX Adults FORMCHECKBOX Children FORMCHECKBOX Clinical trial enrollment FORMCHECKBOX Couples FORMCHECKBOX Families FORMCHECKBOX Home visits FORMCHECKBOX Inpatient FORMCHECKBOX LGBT FORMCHECKBOX Older adults (over 65) FORMCHECKBOX Research only (no practice) FORMCHECKBOX Online Treatment available FORMCHECKBOX Disorders treated (check all that apply)Agoraphobia FORMCHECKBOX Anxiety/Fear FORMCHECKBOX Anxiety and depression FORMCHECKBOX Attention-deficit/hyperactivity disorder (ADHD) FORMCHECKBOX Autism spectrum disorder FORMCHECKBOX Bipolar disorder FORMCHECKBOX Body dysmorphic disorder(BDD) FORMCHECKBOX Body-focused repetitive behaviors FORMCHECKBOX Depression FORMCHECKBOX Eating disorders FORMCHECKBOX Generalized anxiety disorder (GAD) FORMCHECKBOX Hoarding FORMCHECKBOX Obsessive-compulsive disorder (OCD) FORMCHECKBOX Panic attacks/panic disorder FORMCHECKBOX Phobias FORMCHECKBOX Posttraumatic stress disorder (PTSD) FORMCHECKBOX Disorders treated, continuedSelective mutism disorder FORMCHECKBOX Separation anxiety FORMCHECKBOX Social anxiety disorder FORMCHECKBOX Substance Abuse FORMCHECKBOX Tourette and tic disorders FORMCHECKBOX Trauma FORMCHECKBOX Trichotillomania FORMCHECKBOX Practices (check all that apply)Acceptance and commitment therapy (ACT) FORMCHECKBOX Breathing and relaxation techniques FORMCHECKBOX Cognitive-behavioral therapy (CBT) FORMCHECKBOX Dialectical behavioral therapy (DBT) FORMCHECKBOX EMDR FORMCHECKBOX Exposure therapy FORMCHECKBOX Intensive exposure protocols FORMCHECKBOX Interpersonal therapy (IPT) FORMCHECKBOX Medication prescription FORMCHECKBOX Medication referral FORMCHECKBOX Mindfulness FORMCHECKBOX LicensesClinician license #_______________________State _________________________________Please note: You may add anything not listed above to your online practice profile. FORMCHECKBOX I have enclosed a copy of my licensure or certification.Ethics statement In signing below, I verify that I have no ethical violations according to my state and professional code of conduct and I have maintained state licensing requirements.___________________________________________Signature____________________________Date ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download