Personal Information

First Name^*

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Last Name^*

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Email^*

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Username^*

This will be the Username used to access your Membership Benefits

Password^*

Password must be at least 7 characters long. This password will be used to access your Membership benefits.

Enter password again^*

Password must be at least 7 characters long. This password will be used to access your Membership benefits.

Phone

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Address

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City ^*

State or Region ^*

Country ^*

Zip ^*

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Website

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Membership Types^*

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Professional Information

Name of Academic Institution, Fire Department, or Psychological Association (Even if Retired or Alumni)

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Institution, Fire Department, or Psychological Association Address

Address Line 1

City ^*

State or Region ^*

Country ^*

Zip ^*

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Phone Number

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Website of Academic Institution, Fire Department, or Psychological Association (Even if Retired or Alumni)

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Degree, Department, or License Type

Please enter applicable degree level, department, or license type here. Enter highest credential achieved.

Date Awarded

Enter the date your degree or license type was awarded. Please use mm/dd/yyyy format.

License Number

Only for Psychology Associate or Psychologist Member.

Are you interested in becoming an Approved Provider?

Please let us know if you are interested in becoming an Approved Provider.

Confidentiality Agreement I wish to receive consultation services as a member of the Fire Service Psychology Association. I understand that these consultations do not constitute clinical supervision and that I remain completely responsible – ethically and legally – for the decisions I make in my own clinical case situations. My consultant will provide me with an opportunity to discuss clinical cases and issues about which s/he may have some expertise, and s/he may help me consider options for responding, but the comments made for my consideration are not supervision mandates. I also understand that although we may sometimes need to discuss personal issues that may be relevant to my clinical work, these consultation services do not constitute psychotherapy. I understand the potential limits of the confidentiality of this relationship. To the extent possible, my case presentations will provide no identifiable patient information. However, I understand that if I provide identifiable information about a situation regarding which my consultant has an ethical or legal obligation to report confidential information, s/he will inform me at the time and will give me the opportunity to make the report myself. I understand that if my consultant becomes aware that s/he knows or has a prior relationship with the presented client(s), or if she believes she has a potential conflict of interest in her relationship with me, she will notify me of that fact immediately and will cooperate in helping me find a different consultant. I agree there is no fee for the consultation service as long as I am a member of The Fire Service Psychology Association per one-hour consultation session. If I require one on one consultation services, I will reach out to a provider on my own and will make arrangements with this party separate from The Fire Service Psychology Association affiliation. I have read and agree to the following statement. By submitting this application, I am demonstrating my understanding and commitment to this agreement.

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