Member Application Form Apply below! Step 1 of 911%General InformationGeneral information about youName* First Last Degrees & CredentialsPlease list your degrees and credentialsPreferred NameWhat would you like us to call you?Name of BusinessWhat is the name of your business?Business Street Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business PhoneCell PhoneFax NumberEmail* Website How did you find TCA?i.e. Website, Word of Mouth, Social Media, Program, Other?Educational BackgroundLocation of Bachelor's DegreePlease list where you earned your Bachelors DegreeBachelor's SpecialtyWhat was your Bachelor's degree in?Location of Master's DegreePlease list where you earned your Masters DegreeMaster's SpecialtyWhat was your Master's degree in?Other CertificationsPlease list any additional relevant degree or certificationsFocus of PracticeBusiness DescriptionA Brief Description of You/Your PracticeDisclosure of Dual RelationshipsPlease list any dual relationships (ie a financial relationship with a school, program, ancillary service provider, Board, or other organization). The existence of dual relationships does not disqualify an applicant. Click here for more info→Focus of Practice*Please choose all that apply: Adult Services Child/Adolescent Substance Abuse Child/Adolescent Therapeutic Local Support Services Non-Traditional Boarding School Non-Traditional Day School Non-Traditional Young Adult Services Traditional Boarding School Traditional Day School Young Adult Substance Abuse Young Adult TherapeuticNow, please re-order and rank your focus of practice– Fill Out Other Fields –RecommendationsPlease provide Three Recommendations, at least one must be from a Program, and one from a referring professional.ListNameEmailPhone AcknowledgementsEthics Acknowledgement*Acknowledgement of the TCA Guidelines of Professional And Ethical Best Practices Click here for more info→Please select an option...I AcknowledgeI DO NOT AcknowledgeRights And Responsibilities*Acknowledgement of the TCA Rights, Responsibilities, and Benefits of Membership. Click here for more info→Please select an option...I AcknowledgeI DO NOT AcknowledgeActive Engagement*Be actively engaged as a therapeutic referring professional at least 1/3-time (roughly 12-15 clients for referral a year).Please select an option...I AcknowledgeI DO NOT AcknowledgeSites VisitedMembers 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 schoolsListProgram NameProgram LocationContact Upload FilesHighest Degree Picture (old; hidden)Highest Degree Picture Drop files here or Resume / CV (old; hidden)Resume / CV Drop files here or Marketing Materials Drop files here or Marketing Materials (old; hidden)Professional Headshot Photo (optional)Volunteer OpportunitiesThe TCA is an all-volunteer organization focused on Collaboration.Interest AreaIs there any particular area that you would like to support as the organization grows?Membership PlansPlease 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/YearFull Professional with Education Background: $300.00/YearFull Professional Member: $300.00/YearYearly Full Professional with Clinical BackgroundReferring Professional with 2+ years of experience and a clinical background Price: $300.00 Yearly Full Professional with Education BackgroundReferring Professional with 2+ years of experience and an educational background Price: $300.00 Yearly Full Professional MemberYearly Full Professional Member Price: $300.00 Application Fee Consent*A one-time $60 application fee will be added to your first invoice. I understandOne-Time Application Fee Price: $60.00 A one-time fee for us to process your application is $60. This will be applied to your invoice.TotalAn invoice will be emailed to you via the email you provided. $0.00 Prove your humanity:
