LCPCM Membership Application
Note: Items with a * are required fields.
*First Name:
*Last Name:
*Work Telephone:
Fax Number:
*Email Address:
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip:
*Credential type(s):
(Select one or more)
LCPC:
Other:
*Work Setting:
(Select one or more)
Private Practice:
Public Agency:
Hospital Setting:
University:
School:
Nonprofit:
Other:
Home Telephone:
*State Legislative District
*Membership Type:
(Select one)
Regular Membership ($95.00)
Student Membership ($65.00)
Retiree Membership ($65.00)
Check ONLY if you do NOT
want to be published on our website:
Please do
not
list me on the LCPCM website!
Professional Specialties:
Please list three brief entries:
Continue Registration Process:
