Name___________________________________Address______________________________________________

 City__________________________________ Zip____________ Phone___________________________________

 Email_________________________________________________ License/s_______________________________

We will be posting a directory of all PCCA members for referral purposes on this website.  If you are interested in being included in this directory, please complete the following information:

Areas of practice (check those that apply) 

[ ]  Adults                                    [ ] Adolescents                    [ ] Children

[ ] Couples                                 [ ]  Groups                           [ ]  Family

 Areas of Expertise (check those that apply) 

[ ] Anxiety            [ ] Depression       [ ] Personality Disorders      [ ] ADD/HD 

[ ] PTSD             [ ] Drug/Alcolhol    [ ] Domestic Violence           [ ] OCD

[ ] Attachment     [ ] Military              [ ] Bariatric Issues                [ ] Eating Disorders

[ ] Adoption        [ ] Pornography     [ ] Gambling                          [ ] Internet

[ ] TBI                [ ] Sexual abuse    [ ] Med management             [ ] Sex offenders

[ ] Other

 Read and sign to be included in the online directory:  I hereby give permission to PCCA for them to include the above information on their website for purpose of referral.

________________________________________   __________________________________

Name                                                                 Date

Please return application and dues to the above address.

Payment enclosed:  _____Professional  ($60.00)   ____ Associate  ($60.00)

                                _____Student/Retired ($30.00)

For groups seeking membership, please call Mary Phillips Green 425-753-0693 or 253-875-8590.