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WNCPA New Member Application Form

Thank you for your interest in joining WNCPA! Please fill out and submit the form below and a member of our team will reach out to review next steps. Please note that membership information is for WNCPA admin and will not be shared.

General Information
Birthday
Month
Day
Year
Professional Information
What is your current professional role?
Primary Practice Setting
In-Person
Virtual
Hybrid
Other (please specify)
Employment Status
Employed Full-Time
Self-Employed
Unemployed, actively seeking employment
Unemployed, not seeking employment
Retired
If you are seeking employment, would you like to know about possible employment opportunities?
Yes
No
N/A
WNCPA Membership Options
Please select your membership plan:
Regular membership ($40) - I am an active member and can pay annual membership dues.
Early career psychologist - I am in the first five years of practice post-licensure (Free membership for 1 year)
Retired Psychologist - I am a retired professional (Free membership)
Humanitarian Psychologist - I work in an under-resourced institutions serving marginalized populations and who have limited financial means (Free membership for 1 year)
Experiencing Financial Hardship - I am unemployed and actively seeking work, or I am currently experiencing financial hardship. (Free membership for 1 year)
Additional Information
Identity Demographics (Optional)
What is your sexual orientation?
Straight / heterosexual
Gay or lesbian
Bisexual
Queer
Prefer not to answer
Prefer to self-describe:
Do you identify as transgender?
Yes
No
Prefer not to answer
Do you identify as part of any historically marginalized or underrepresented group within the mental health field? (e.g. BIPOC, LGBTQ+)
Yes
No
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