NYMHCA 
Regional Chapter Member Information Form
You are filling out this form because when you joined NYMHCA you also joined your regional chapter.  Your chapter’s leaders want to know about you, your needs and how you could contribute to the chapter.  Please fill out the form below and click on the Submit button at the bottom.

All information on this form is optional but the more information you give us, the better your chapter can provide you with the experiences you need.

Please check the name of the chapter you have joined::
 
                                         
     
    
                                           
     

Name:
Title:  (Ph.D, MS, MA, etc,)
Membership Type.  Check one:
Email Address:
Date:
Licenses: (LMHC, LMFT, LPC, etc,)
Mailing Address:
Phone:  (cell?)
What topics would you like to see presented at a chapter meeting?
Please list your skills and areas of expertise:
Would you be interested in making a presentation at a future meeting?
Do you have experience in leadership positions in other organzations?
If yes, would you be interested in a future leadership position in your chapter?
Thank you for providing the above information.  Once you click on the SUBMIT button below this form will be forwarded to your chapter leaders.
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No
Yes
Yes
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