Adoptee-Therapist Directory Annual Membership Renewal

Name *

First

Last

States under which you are currently listed in the directory: *

Indicate any revisions you would like to make to your current listing.

Example: New contact information, new website, change in population age of clients, additional specialties, additional states of licensure, etc. Note that all revisions must fit appropriately within the categories available on the directory (i.e. insurance is not a listed category).

Upload an image of licenses in all states where you would like to be listed. If you are a PSYPACT provider, upload a copy of your home state license and APIT certificate. *

Click or drag files to this area to upload. You can upload up to 10 files.

Annual Directory Membership Renewal Fee *

This renewal payment is due by Jan. 31, 2025. Your profile will be listed for a period of 1 year beginning Feb. 1, 2025. If you choose to resubmit a new profile after Jan. 31, 2025, it will be listed for a period of 1 year from the date it is posted. A renewal reminder will be emailed to you 30 days prior to the end of your listing period.

By checking the box below, I confirm that the information I've entered above is true and accurate. I understand that an additional fee will be charged to make any updates or revisions to my profile after this form has been submitted. If I am not eligible to be included and have submitted this form in error, I understand that I will receive a full refund minus a $35.00 administrative fee. If my profile must be removed by the administrator for any reason during my membership period at the administrator's discretion, I understand that I will receive a prorated refund minus a $35.00 administrative fee. *

I confirm my understanding and agreement with the statements above.

Stripe Credit Card *

Total

$0.00