Ohio Psychological Association MEMBERSHIP APPLICATION

First Name: ______Last Name: ______Degree: ______

Ohio License Number (if applicable): ______Ohio Date of Licensure (if applicable - MM/DD/YYYY): ______

Other State Licenses (if applicable): ______Date of Birth (MM/DD/YYYY): ______

Email Address (Online UserName): ______Online Password : ______(Minimum 8 characters, 1 upper case letter and 1 number or special character) Select Membership Category:

Benefactor Members: Must be Licensed or Non-Licensed with Doctoral Degree to be eligible for these categories. Category Dues Description President’s Club members receive a $75 OPA promotional code, free Premium listing in the q President’s Club $750 Find-a-Psychologist Referral Program, special notation in quarterly OPA publications and on the OPA website, and are invited to attend the annual President’s Club dinner. Sustaining Members receive a $50 OPA Continuing Education promotional code, a free q Sustaining $450 Premium listing in the Find-a-Psychologist Referral Program, and special notation in quarterly OPA publications and on the OPA website. Full Members: Must be Licensed or Non-Licensed with Doctoral Degree to be eligible for these categories. Category Dues Description q Career Experience 7 + years $360 Licensed or Non-Licensed with Doctoral Degree and have 7+ years of career experience. q Career Experience 5 – 6 years $225 Licensed or Non-Licensed with Doctoral Degree and have 5-6 years of career experience. q Career Experience 1 – 4 years $150 Licensed or Non-Licensed with Doctoral Degree and have 1-4 years of career experience. q Career Experience under 1 year $100 Licensed or Non-Licensed with Doctoral Degree and have less than 1 year of career experience. $75 - Age 65 and Over and fully retired – A separate application is required for NEW members of this q Emeritus / Fully Retired $250 category. Please call OPA at 614.224.0034 for application. Affiliate Members: Ineligible to vote or hold office, and have limited participation on OPA listservs. Category Dues Description q Student $25 Middle School, High School, College Undergraduate and College Graduate Level Professional working in field of Psychology or Individual / Organization who wishes to support/ q Partner $50 advance the purpose of OPA and the field of psychology in Ohio. Discounts are available for individuals who are: not currently practicing or teaching in Ohio; not currently employed in the field of psychology; working 20 hours or less a week; or, currently undergoing financial hardship or special circumstances (based on IRS reported gross income). Contact the OPA Central Office at 614.224.0034 for more information. Please note, additional documentation is required.

Contact Information: PERSONAL (HOME) CONTACT INFORMATION: PROFESSIONAL CONTACT INFORMATION: Street Address: Organization / Business Name: ______City, State Zip: Street Address: ______County: City, State Zip: ______Home Phone: County: ______Mobile Phone: Business Phone: Business Fax: ______Website: May OPA Contact You Via: q Fax q Email ______Preferred Mailing Address: q Home q Professional Demographic Information (Optional): Email Lists / Online Forums: Outreach Contributions:

Gender: q Male q Female OPA provides numerous COMPLIMENTARY Contributions / donations to the following programs online forums and listservs to help members / activities may be made in conjunction with your Race / Ethnicity: membership dues payment. Please see the back page of stay connected. Select (s) you would q American Indian/Eskimo this application for instructions. q Appalachian like to subscribe to below: q Asian/Asian American q General Forum (OPA-LINK) - Subscribe OPA-PAC (Political Action Committee): q Black/African American to OPA’s open member forum to OPA-PAC supports state political activities q Hispanic/Latino/Latina network and discuss current issues in that impact psychologists and consumers by q Pacific Islander the field of psychology. (Affiliate members contributing to campaigns and candidates. q White are not eligible to participate on this list..) As an unincorporated political action q Bi/Multi-Racial q committee, contributions are not tax q Other News Flash (OPA-NEWS) - NO CHAT LIST Periodic news/announcements from deductible. NO CORPORATE CHECKS OR Professional Setting: OPA Central Office. CORPORATE CREDIT CARDS can be accepted q Academic for payment of your OPA-PAC donation. q Forensics (OPA-FORENSICS) - OPA'S q Business Payment Options: q Hospital forum for forensic psychologists and issues related to the field of psychology. • Personal Check (payable to OPA-PAC q Military • Personal Credit Card q Private Practice q Early Career Psychologist (OPA-EARLY) - • Donations can be made in one lump sum q Public Sector OPA’s forum for recently licensed or in 4 equal monthly installments. q Retired individuals to discuss early career issues. Salary Range: q LGBT (OPA-LGBT) - Subscribe to OPA Project FAIR q $0 - $19,000 discussion on lesbian, gay, bisexual, and (Focused Advocacy Insurance Reform): q $20,000 - $39,999 transgender issues pertaining to the OPA Project FAIR was founded in 1997 to q $40,000 - $59,999 field of psychology. address the mounting concerns psychologists q $60,000 - $79,999 have with managed care and insurance q q $80,000 - $99,999 Neuropsychology (OPA-NEURO) - OPA’s company problems. Contributions to this q $100,000 - $124,999 forum for neuropsychologists and issues fund are tax-deductible. related to the field of psychology. q $125,000 - $149,999 Payment Options: q $150,000 + q Prescriptive Privileges (OPA-RxP) - • Personal or Corporate Check (payable to Forum for individuals to discuss issues OPA-FAIR) Affiliation Information: relevant to advocating for prescriptive • Personal or Corporate Credit Card privileges for psychologists in Ohio. • Donations can be made in one lump sum Are you a member of.... (Check all that apply.) or in 4 equal monthly installments q Small College (OPA-SM-COL) - Forum q American Psychological Association to encourage dialogue and facilitate If yes, which APA divisions? The Foundation for Psychology in Ohio: collaboration among small college The Foundation is a non-profit, charitable ______psychology faculty in Ohio. ______organization that supports educational q Student (OPA-STUDENT) - Subscribe programs, scholarships, Science Day prizes, REGIONAL ORGANIZATIONS: to this open forum to network research and other programs that benefit q Akron (AAPP) and discuss current student/new the science and practice of psychology. q Central Ohio (COPA) psychologist issues in psychology. Contributions are tax deductible. q Cincinnati (CAPP) q Cleveland (CPA) Payment Options: q Dayton (DAPA) • Personal or Corporate Check (payable to The Foundation for Psychology in Ohio) q Toledo (TAAPP) GRASSROOTS ADVOCACY: • Personal or Corporate Credit Card OTHER PSYCHOLOGICAL GROUPS: q Are you interested in helping to • Bequests, Insurance Policies, or Real q Ohio School Psychologists Association promote psychology’s legislative and Estate (call OPA for more information) (OSPA) regulatory agenda by receiving and • Donations can be made in one lump sum responding to timely advocacy alerts? or in 4 equal monthly installments q Ohio Women in Psychology (OWP) q Ohio Psychiatric Physicians Association Deductibility: Dues payments, contributions or gifts to the Ohio Psychological Association are not q Asian American Psychological tax deductible as charitable contributions for tax MEDIA RESOURCE GUIDE: purposes. They may be deductible as ordinary Association (AAPA) and necessary business expenses subject to the q Association of Black Psychologists q Are you willing to be contacted by restrictions imposed as a result of lobbying activities. OPA estimates that for the Association’s fiscal year (ABPsi) media regarding issues in psychology? Those who select to participate will 9/1/15 to 8/31/16, 20% of dues were allocated to q lobbying activities and are non-deductible; OPA Natl Latino Psychological Association be contacted for detailed information estimates that for the Association’s fiscal year 9/1/16 q Society of Indian Psychologists (SIP) about your media preferences. (Students to 8/31/17, 20% of dues will be allocated to lobbying are not eligible to participate.) expenditures and are non-deductible. Gifts to the q Other ______foundation and OPA-FAIR are tax deductible. Areas of Competency / Specialty / Focus: Online Referral Program: Practice Orientation: Treatment & Practice Areas:(Select ALL that apply) Consumers can search anonymously 24 hours (Select ALL that apply) q ADHD/ADD q Leadership Development a day 7 days a week at www.ohpsych.org q Acceptance & q Adolescent Issues q Learning Disorders on our “Find a Psychologist” search engine Commitment Therapy q Adoption/Foster Care/ q Life Transitions for clinicians based on geographic location, q Afrocentric Custody Issues q Marriage/Couples practice orientation, specialty or even hours q Behavioral q Adult General Practice of operation. OPA handles a minimum of 10 q Biological q Alcohol Abuse q Men’s Issues telephone referral requests per day, and the q Brief/Solution Focused q Alzheimers / Dementia q Mental Health online referral page receives approximately q Cognitive-Behavioral q Anger Management Assessment 475 views per week... our referral program q Dialectical q Anxiety q Neuropsychological is a well-known go-to resource for both Behavioral Therapy q Autism/Pervasive q Obsessive/Compulsive consumers and providers alike. q Eclectic Developmental Disorders Disorders q Experimental q Behavioral Problems q Pain Management Members can opt-in for a COMPLIMENTARY q Family Systems q Bipolar Disorder q Panic Attacks/Panic Disorder listing OR upgrade to a premium listing q Feminist q Body Image q Parenting Issues which includes special recognition on our q Gestalt q Career Counseling q Pediatric Psychology website viewable from every page on q Humanistic q Child Abuse/Neglect q Personality Disorders our site. A premium listing is included q Industrial/Organizational q Child Psychology q Phobias with all President’s Club and Sustaining q Jungian q Childhood Issues (Adults) q Police Assessment and Memberships. This member benefit is only q Mind/Body q Chronic Illness/ Counseling available to Ohio licensed psychologists. q Multi-Cultural Therapy Physical Disabilities q Post Traumatic Stress q Neuropsychological q Coaching q Pregnancy/Childbirth/ Referral Program Options: q Pastoral/Spiritual q Co-dependency Postpartum q Complimentary listing q Psychodynamic q Couples Counseling q Pre-Surgery q Premium listing - q Rational Emotive Theory q Court Ordered Assessments q Psychopharmacology Licensed 7+ years ($30) q Transactional Analysis q Crisis Intervention q Psychosomatic Issues q Premium listing - q Transpersonal q Cross-Cultural/Social Issues q Rehabilitation Issues Licensed 0-7 years ($15) q Cults q Relationship Issues Tests and Evaluations: q Custody Determination q Religious/Spiritual Issues If you opted to participate in OPA’s Online q Death and Dying q Return to Work Referral Program, please take a moment to Do you administer tests q Depression q Schizophrenia/Psychotic answer the following two questions which and evaluations? q Developmental Disabilities Disorders will help to complete your online profile. q Yes q No q Disability Evaluations q School Related Issues Should you wish to update your profile you q Dissociative Identity q Self-Esteem Issues may do so at your convenience online once Language Fluency: Disorder q Sexual Abuse/Rape/ your application for membership has been (Select ALL that apply) q Divorce Issues Incest: Offenders processed. q American Sign Language q Domestic Violence: q Sexual Abuse/Rape/ q Arabic Offenders Incest: Victims What are your days / hours of operation? q Chinese q Domestic Violence: q Sexual Addiction (Select ALL that apply) q French Victims q Sexual Dysfunction q Weekday q German q Eating Disorders q Sexual Therapy q Evening q Hebrew q Elder Abuse/Neglect q Shopping Addiction q Saturday q Italian q Emotion Regulation q Sleep Disorders q Sunday q Japanese q Exposure Treatment q Smoking Cessation q Russian q Eye Movement q Sports Psychology What types of fee arrangements q Spanish Desensitization and q Step-family Issues do you accept? q Vietnamese Reprocessing q Stress Management (Select ALL that apply) q Family Therapy q Substance/Prescription q Medicaid q Forensic Evaluations Drug Abuse q Medicare Population Served: q Gambling q Suicide Evaluation/ q Self-Pay (Select ALL that apply) q Gay/Lesbian/Bi-Sexual/ Intervention q Sliding Scale q Children, Ages 0-6 Transgender Issues q Surgical Evaluations q Some Insurance Plans q Children, Ages 7-11 q Geriatrics q Trauma Counseling Names of insurance plans: q Adolescents/Teens q Gifted Children q Veteran/Service Member ______q Adults q Grief Counseling Issues ______q Couples q Health Psychology Issues q Violence/Violence Potential ______q Families q HIV/AIDS q ______q Hypnosis q Women’s Issues ______q Hypochondria q Workers Compensation q Workers Compensation q Infertility Issues q Internet Addictions q Workplace Consultation Professional Ethics Declaration and Signature: If you have answered “yes” to any of the questions to the right, 1. Have you ever been denied membership by... please attach the following to your application: (a) a brief description • a Professional Organization? qYes qNo of the matter, (b) its final result or current status and (c) any key • a State Licensing/Credentialing Board? qYes qNo documents regarding the charges, your defense and any ruling. 2. Have you ever had any action taken against you as the result of a I have read and I agree to abide by the APA Ethical Principles of review or investigation by... Psychologists and Code of Conduct*, which has been adopted by the • a Professional Organization? qYes qNo Ohio Psychological Association. I understand that this application • a State Licensing/Credentialing Board? qYes qNo is subject to review by the OPA Membership Committee and that should my application be denied by the Board of Directors, I have 3. Are you presently under investigation by... the right to make an appeal to said Committee. I understand that • a Professional Organization? qYes qNo providing OPA with incomplete or inaccurate information may result • a State Licensing/Credentialing Board? qYes qNo in membership being denied or rescinded. 4. For reasons concerning/in connection with an ethical or legal ______issue, have you ever voluntarily or involuntarily relinquished: Print Full Name of Applicant • a professional work responsibility? qYes qNo • a professional organization membership? qYes qNo ______Signature of Applicant 5. Have you ever been indicted for or convicted of a felony? qYes qNo ______6. Have you ever... Date • been a party to an out-of-court settlement involving actual *The APA Ethical Principles of Psychologists and Code of Conduct can be found on or claimed malpractice? qYes qNo either the APA website at www.apa.org or the OPA website at www.ohpsych.org (click • had a malpractice judgment entered against you in any on “About OPA” and then “Leadership”). court proceeding or arbitration hearing? qYes qNo

Payment Instructions: PAYMENT CALCULATOR: PAYMENT METHOD:

Membership Dues $ ______+ q Check or Order - Payable to OPA* (To pay for 2 years of membership, * Contributions to PAC, Project FAIR or the Foundation, double your dues amount.) should be paid for by a separate check. Please follow the guidelines below for each donation. Premium Referral (Optional) $ ______+ • PAC: Checks payable to OPA-PAC / PERSONAL CHECKS ($30 Licensed 7+ years, $15 Licensed less than 7 years) ONLY (If paying for 2 years of membership, double this fee as well.) • Project FAIR: Checks payable to OPA-FAIR • Foundation: Checks payable to The Foundation for Optional Support/Donations: (see application for more information) Psychology in Ohio PAC (suggested $25) $ ______+ q Credit Card – One Lump Sum Payment Project FAIR (suggested $10) $ ______+ q Credit Card – 4 Equal Installments Foundation (suggested $15) $ ______+ (First installment will begin upon approval of this application.) Paper Membership Application Fee $ ______5.00 + q VISA q MasterCard q AMEX (Avoid this fee, join online at www.ohpsych.org.) ______Installment Payment Fee $ ______+ Credit Card Account Number (If you opt to spread your payments over 4 equal installments, please add a $10 administration fee.) Expiration Date: ______Security Code: ______

Couples Discount $ ______- ______Married or life partners, who are FULL OPA Signature members, may reduce one (1) of their memberships by $25. If you are taking this discount, please list MAIL OR FAX YOUR COMPLETED FORM TO: the name of your partner. Ohio Psychological Association ______395 East Broad Street, Suite 310 | Columbus, OH, 43215 Phone: 800-783-1983 or 614-224-0034 | Fax: 614-224-2059 TOTAL AMOUNT DUE ………………… $ ______Website: www.ohpsych.org