AGENCY MEMBERSHIP

AGENCY MEMBERSHIP
Name Person Submitting Application*

FirstLast
Position at Agency:
Agency EIN:
Email*
example@example.com
Agency Address*

Street Address

Street Address Line 2

CityState

Zip Code
Agency Phone Number

Area CodePhone Number
Agency Website:

Types of Placement Available:
The National Consortium for Mental Health Counselors reserves the right to decline membership. Membership is offered to students, residents, professionals, and agencies in the mental health field. The decision to make this a closed group organization benefits the members of the mental health profession. Questions and concerns about seeking membership outside of the normal parameters can be addressed by emailing Info@ncmhc.org.
Security Questions
Mother's Maiden Name
Make and Model of First Car
Your favorite Pets Name
Privacy Statement
The National Consortium for Mental Health Counselors respects your privacy. As a member of the consortium, your information may be requested by internal partners, agencies, and other clinicians, for intern opportunities, residencies, and/or collaboration. Please make your selection below, to serve as your signature to share or not share your email address only!
I give the National Consortium for Mental Health Consolers permission to share the following information with internal partners or members.*

Share email onlyShare Telephone onlyShare email and telephone
Note, once you hit submit your request for membership will be submitted. Memberships are non-refundable and cannot be reversed. Before selecting submit review your personal information for accuracy to ensure your listing is accurate in the system. Click to edit this text...
To make your payment, please select the correct option aligning with your selected membership. All major credit cards accepts.
Agency Membership*
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6 Month Affiliation$700.00

Quantity

Annual Agency Affiliation$1,200.00

Quantity

Total $0.00
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AGENCY MEMBERSHIP

Security Questions

Privacy Statement