Member Application Form

General Information
General information about you
Name*
First Last
Degrees & Credentials
Please list your degrees and credentials
Preferred Name
What would you like us to call you?
Name of Business
What is the name of your business?
Business Street Address
Street Address City State
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Business Phone
Cell Phone
Fax Number
Email*
Website
How did you find TCA?
i.e. Website, Word of Mouth, Social Media, Program, Other?

Educational Background
Location of Bachelor's Degree
Please list where you earned your Bachelors Degree
Bachelor's Specialty
What was your Bachelor's degree in?
Location of Master's Degree
Please list where you earned your Masters Degree
Master's Specialty
What was your Master's degree in?
Other Certifications
Please list any additional relevant degree or certifications

Recommendations
Please provide Three Recommendations, at least one must be from a Program, and one from a referring professional.
List
Name Email Phone

Acknowledgements
Ethics Acknowledgement*
Acknowledgement of the TCA Guidelines of Professional And Ethical Best Practices
Click here for more info→
Rights And Responsibilities*
Acknowledgement of the TCA Rights, Responsibilities, and Benefits of Membership.
Click here for more info→
Active Engagement*
Be actively engaged as a therapeutic referring professional at least 1/3-time (roughly 12-15 clients for referral a year).

Sites Visited
Members of TCA visit, on average, 40 programs and schools a year, with at least 25 of them being unique visits. Up to 15 may be repeat visits within the same year, and at least 1/2 must be therapeutic schools or programs. This can include local day schools
List
Program Name Program Location Contact

Volunteer Opportunities
The TCA is an all-volunteer organization focused on Collaboration.
Interest Area
Is there any particular area that you would like to support as the organization grows?

Membership Plans
Please indicate which membership plan you would like to participate in. Once your membership is approved, you will be able to pay the fee from your Member Dashboard.
Please select your membership plan:
- Full Professional with Clinical Background: $300.00/Year
- Full Professional with Education Background: $300.00/Year
- Full Professional Member: $300.00/Year
Yearly Full Professional with Clinical Background
Referring Professional with 2+ years of experience and a clinical background
Price:
Yearly Full Professional with Education Background
Referring Professional with 2+ years of experience and an educational background
Price:
Yearly Full Professional Member
Yearly Full Professional Member
Price:
Application Fee Consent*
A one-time $60 application fee will be added to your first invoice.
I understand
One-Time Application Fee
Price:
A one-time fee for us to process your application is $60. This will be applied to your invoice.
Total
An invoice will be emailed to you via the email you provided.
$0.00
Prove your humanity:

Apply below!

Name	Email	Phone

Program Name	Program Location	Contact