Renew or Update VTMHCA Membership Info

All active VTMHCA members will be included in our directory listing as a part of membership. Your contact information and "Characterizing Your Practice" will be accessible to visitors who are looking for a therapist on the VTMHCA.org website.

Please Note: All information marked with an asterisk (*) is visible on your directory listing. Home address and phone will not be displayed unless it is your workplace and you insert it into Office fields.

We suggest you review some of the completed listings prior to filling out the form below.

Current Members Updating Information:

  • Complete the membership form below to make changes to your information
  • Choosing a region is essential for new clients to find you
  • At the end of entering fields, click on “Join, Update or Renew Now,”
  • Fields left blank will not overwrite existing information you gave previously
  • Type the word “delete” in any field you wish to make blank

Renewing Members:

Follow directions as if current member, click “Join, Update or Renew Now” and choose payment method. Your listing will not reappear until your payment is received.

You may pay by PayPal or mail a check.

Fields in red are required.

Personal Information
*Last Name: *First Name:
Middle Initial:  
Home Address:
Town/City: State: Zip
Home Phone: Email1 (Personal):
Professional Information
*Place of Employment:
*Office Address:
*City: *State: *Zip:
*Email2 (Office): Cell or Other Phone:
*Office Phone: Fax:
Work Setting: Private Practice
Hospital
Non Profit
Agency
Alternative Ed.
*Website: http://
Membership Information
Membership Level:
Are you a student? Yes  No
If you are a student, enter your professor's name for verification
Region:
 
(hold down Ctrl while clicking to select multiples)
Are you a member of AMHCA? Yes   No
Unified Dues Program:
Join both VTMHCA & AMHCA and receive a 20% discount on both memberships. For more information and to join both, please go to: www.amhca.org/join/ (This link will open a new window so that you may retain this website in this browser window. Please complete this form first and then proceed to AMHCA membership.)
*List any degrees that you hold:
*List any other pertinent education
*List other associatons in which you hold membership
*Select any licenses you hold.
 
(hold down Ctrl while clicking to select multiples)
*Areas of Experience:
 
(hold down Ctrl while clicking to select multiples)
Characterizing Your Practice
*Counselor Type: (select all that apply)
Adults
Adolescents
Children
Elders
 Individual
Couple
Family
Group
*Give us a brief explanation of your philosophy (max 255 characters)
*Type of Therapy
*Years in Practice
*What's the best way to schedule an appointment?
(select all that apply)		 Call
Email
Write
*Payment Types Accepted:
(select all that apply)		 Cash
Credit Card
Check
Other
*Do you accept insurance? Yes  No
*Types of Insurance Accepted:
Directory Information
Choose a UserID: (editing capability may be added in the future)
Choose a Password:
By submitting this form you agree to allow us to contact you by email to inform you of industry news, important information and renewal notices.