"GLITSE" Membership Application

Membership is open only to licensed* therapists who have special experience and or training in working with gender issues. Print this page and mail or fax with your membership fee (listed below) to the above address. 

Name(s)________________________________________________________

_______________________________________________________________

Organization _________________________________________________________

Address ____________________________________________________________

City __________________________State ___________ 

Zip Code____________________________________________________________

Communities Served (list a maximum of 5 cities):

____________________________________________________________________

E-mail address _______________________________________________________

Do you check email regularly (y/n)

URL (if applicable): ____________________________________________________

Office number: ________________________________________________________

Fax number:__________________________________________________________

License type and # (if applicable).________________________________________

License expiration date (if applicable).__ ___________________________________

Number of years in practice ______________________________________________

Treatment Model: ____________________________________________________

Treatment Settings that Apply (circle all that apply):

Individual Counseling/Private Practice

Medical Evaluation

Community Mental Health

College/University Counseling Program

Residential Setting 

Outpatient

Inpatient

Support Groups

Other:_______________________________________________________________

Diagnostic Categories/Populations Served (circle all that apply):

Fee Schedule (circle all that apply):

Sliding scale

Insurance

Cash

Credit Cards

How did you hear about us?___________________________________________

Other affiliations? ______________________________________

Have you ever been named as a defendant in a malpractice action in the past five years or are there currently any professional liability complaints pending against you? (Circle YES or NO). If yes, explain in full on back of sheet.

Have you ever been denied membership or a renewal thereof, or been subject to disciplinary proceedings by any local, state or national professional society?

(Circle YES or NO). If yes, explain in full on back of sheet.

Sign below indicating that the above information is true and accurate.

X ___________________________ Date _______________

Please forward the following items with membership form:

You may fax this information, if paying through paypal, to: Glitse/fax 760 633-3366

If you would prefer automatic renewal until you notify us otherwise, check here: yes/auto renewal ______.

Brochure or information on your services provided(if available).

You will be notified when your application is received. Thank you for your interest.

Annual Membership Dues: 

YOU CAN PAY ONLINE WITH PAYPAL BY CLICKING ON THE PAYPAL BUTTON NEXT TO EACH SELECTION 

If you pay with PayPal, then you can fax your application to us at fax: 760 633-3366

$125 Individual Membership (licensed* professionals)

$175 Group Membership (must have a minimum of one licensed* professional)

$275 Treatment Centers/Facilities Membership

 

*Some states do not required practitioners to be licensed but rather certified in their area of expertise. Further, interns with an intern number and supervisor can become part of the organization. 

One referral is all it takes to make back half membership dues for the entire year!