NESTTD Membership  Application

For membership consideration, please print and fill out this application. Send it, along with applicable documentation and a dues check made out to NESTTD.  Send to: Member Services Director, NESTTD, PO Box 506, Malden, MA 02148

Today's Date _________/_________/__________

qNew Member         qRenewal

Name ______________________________________________________

Professional Degree _______________________

Mailing Address (for publication in our directory)

___________________________________________________________

___________________________________________________________

___________________________________________________________

Affiliated Institution (if applicable) ________________________________

Business (for publication in our directory) __________________________________

Fax (for publication in our directory) __________________________________

Email (for publication in our directory) __________________________________

Are you currently a member of ISSD?      qYes             q No

Related Work Experience (for directory — check all that apply)

qChild          qAdolescent        qAdult        qFamily/Couples  

qGroups      qResearch            qTeaching           

Please check appropriate category and complete that section

qFull Membership $100 (professionals involved in treatment, research, or teaching.)                                   

Please include a copy of your license or certificate.

qStudent Membership  $60                                                                                                                         

Please include verification of your student, intern or post-doc status.

    Educational institution name & address:

qAgency Employee Membership*  $60                                                                                                                                        

Please include a copy of your license or certificate.

*The above reduced fee is not applicable to members of group practices or to those

who work in both agency and private practice. The reduced fee is intended to assist

those clinicians who work with low income or under-served clients, have large caseloads,

and receive more limited financial compensation for their work.                                                                     

Agency name & address:

_____________________________________________                                                                                                                                     

Signature

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