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  AGPA Membership Application

This membership application is not yet available for submission online. To apply for membership, please complete form online, print and mail to the address below. Enclose applicable dues for the current membership year. Benefits commensurate with dues payment. 

Please provide the following contact information:

Name
Degree
Office address
Address (cont.)
City
State
Zip
Office Number
Home address
Address (cont.)
City
State
Zip
Home Number:
Fax
E-mail
Date of Birth
Sex Male   Female
Referred by
Signature
Date

  1) Which address do you prefer to receive all AGPA mailings? (You may

  only check one.)

     Home            Office 

 

  2) Which address do you prefer to be posted on AGPA Member’s Online  

  Directory? (You may only check one.)

  Home            Office  

Membership Type:

 Please check one of the following:

Associate Clinical - For those with a Masters Degree and the highest level of state licensure and/or appropriate certification. (Complete Sections I, III and IV)
Adjunct - For those who have experience leading therapeutic, educational and/or consulting groups. (Complete Sections I, II, III)
New Professional - For those who have graduated within three years.(Complete Sections I and III)
Student/Resident - Verification of full-time status must be enclosed. (Complete Sections I and III)
Academic - For those with at least a Master's Degree who have held a faculty position at an accredited institution, including an academic appointment for a minimum of three years. (Complete Sections I, III and V)
Research - For those with at least a Master's Degree who have published a minimum of two research papers in group studies. (Section I, III, VI)

          SPECIAL NEW MEMBER INTRODUCTORY MEMBERSHIP RATES

For Those Applying Between:

For Associate/Adjunct/

Academic/Research:

For New Professional/Student:

January 2007 – June 2008 (18 month rate)

$195

$95

April 2007 – June 2008 (15 month)

 $160

$80
July 2007 – June 2008 (full-year rate) $130 $65
Method of Payment
Check
Charge

Credit card
Cardholder name
Card number
Expiration date
 

Section 1 - Professional Education

Degree and Year Granted:
Institution:
Dates Attended:
Major, include clinical focus:
Degree 2 and Year Granted:
Institution:
Dates Attended:
Major, include clinical focus:

 

Section II - Experience Leading Groups
           Type of Group:
Institution:
Dates:
Responsibilities:
         Type of Group 2
Institution:
Dates:
Responsibilities:

 

Section III - Professional Designation


Please check one of the following:

Certified Group Psychotherapist (CGP) by the National Registry of Certified Group Psychotherapists (NRCGP)
(All CGPs are accepted at the Clinical Membership Level
and do not need to provide the additional information requested below.)
Psychiatrist
Psychologist
Social Worker
Nurse
Marriage and Family Therapist
Clinical Mental Health Counselor
Creative Arts Therapist
Drug & Alcohol Abuse Counselor
Pastoral Counselor
Other, please specify and complete Section II.

 

Section IV - Clinical Credentials


State Disciplinary Licenses 

State:
     License Number:
Title of License:
Expiration Date:

 

- OR -

 

Designated National Certifications or Membership

Organization:
Certificate Number:
Level of Membership/
Certification:

 

Section V - Faculty Appointments

Faculty Position:  
Academic Appointment:  
Institution:  
Dates:  
Faculty Position 2:  
Academic Appointment:  
Institution:  
Dates:  

 

Section VI - Publications

Title of Article/Publication:
Journal or Publisher:
Year:
Title of Article/Publication 2:
Journal or Publisher:
Year:

AGPA’s 18 SPECIAL INTEREST GROUPS are on the move! They are developing in membership, structure and organizational support while giving recognition and identity to special areas of common interest to members. Join a SIG or renew your interest now by making your selection below. You may check one or more.
Addiction and Recovery
 Provides a forum for those with an interest and expertise in utilizing group methods for the treatment and healing process of addictions. 
Children and Adolescents 
Provides a focal point for clinicians treating children and adolescents, furthers training standards and compiles educational resources.
College Counseling and Other Educational Settings SIG
For those who use group processes in any educational setting from early childhood to postgraduate schools.
Combined Long-Term Psychotherapy
This SIG includes any interested parties currently practicing long-term combined psychotherapy and those with even a passing interest in doing so. The SIG membership, which typically practices weekly individual and group psychotherapy, explores the long-term psychotherapeutic relationship.
Co-Therapy
Provides a forum for exploration of issues pertinent to the utilization of co-therapy in groups.
Diversity
Addresses the needs of minorities in group psychotherapy through programming development relating to multi-cultural issues. This SIG also aims to increase minority representation and participation within the organization’s leadership and membership.
Gay, Lesbian, Bisexual and Transgendered Issues
Provides programming, networking and social events for gay, lesbian and bisexual therapists and anyone interested in better understanding homosexuality and bisexuals.

Geriatrics SIG (In-Formation)

Provides a forum for people who work in groups with Geriatric Patients.  Discussion will focus on clinical issues, training, and research.
Groups in Private Practice
Explores issues relevant to establishing and maintaining a private practice of group therapy.
International Relations
Serves as liaison to the International Association of Group Psychotherapy, and encourages and enables members abroad to affiliate themselves with AGPA. Participates in professional and scientific exchanges among group psychotherapists in various parts of the world.
Large and Median Groups and Group Analysis (In Formation)
A learning and sharing forum for people interested in larger group dynamics (median and large groups) and how they offer enriching process for diverse applications from healthcare to global communications. Also, for integrating group analytic perspectives toward training and professional development. 
Medical Illness
Provides a forum for those with an interest or expertise in utilizing group methods to provide psychological treatment to the medically ill.

Organizational Development and Consultation

Provides a home for members who have incorporated organizational consultation work into their professional repertoires.  The utilization of group dynamics principles will be a focus for this SIG.
Psychiatry
Not limited to psychiatrists, this SIG is for those who work in psychiatry departments, have training in psychiatry, or are interested in the application of group psychotherapy in the discipline of psychiatry.
Research
For those interested in stimulating, conducting or furthering their understanding of research in the field of group psychotherapy.
Senior Members
Stay connected and let AGPA know how its most senior clinicians can best be served and wish to continue their participation in their professional home. This SIG provides an opportunity to also share experiences and opportunities that life transitions offer.
Severe and Persistent Mentally Ill
Addresses group treatment of the chronically mentally ill (day treatment settings, other rehabilitation programs, sheltered living and/or functioning independently) to explore the totality of the diverse needs of this population and the place of group treatment for them.
Women in Group Psychotherapy
For those interested in the topic of women and their role in group psychotherapy, whether as patients in groups, leaders of groups, or leaders in their professional organizations.

I am interested in certification. Please send additional information about the National Registry of Certified Group Psychotherapists.
Please mail completed form, payment, and required additional information to:

American Group Psychotherapy Association
c/o Chase Manhattan Bank
Church Street Station
P.O. Box 6359
New York, NY 10249-6359