Membership Renewal Form

Please note that only your name and email address are required items. All other fields need completion only if your information has changed. To renew, submit this form with your annual payment of $75 (see Membership page for payment options). Thank you!

 

* Indicates a required field.

First Name*
Middle/Init
Last Name*

Email*

Only complete those fields below that have changed.

Primary Address
City/State/Zip
Second Address
City/State/Zip
Primary Phone (for publication)
Secondary Phone (for publication)

Website URL

Credentials

Practice Name

Description of Your Practice

Notify me of routine Guild business via

Issues and Concerns

Treatment Modalities

Special Treatment Populations Check as many as apply

AdolescentsAdultsChildrenCouplesFamiliesGay and LesbianGeriatricsTransgender
Additional Services

Community WorkshopsGroup TherapyProfessional SupervisionProfessional Training

Description of Additional Services

Insurance Payments

Not applicable, there is no fee for service provided.Private pay only, no insurance accepted.Private pay, limited insurance provider.Will provide receipt to submit for out-of-network reimbursement.Sliding scale or reduced fee possible.Preferred provider for many insurances.

Insurance Providers

AetnaAlliantAnthemAPSBridgespan HealthCignaCrime VictimsDSHS/Medical CouponsFirst ChoiceGreatWest Health CareHelplineKaiser PermanenteKaiser Permanente PPOL&ILifewise PremeraMagellan Health ServicesMedicaidMedicareMHNMolinaPremeraRegenceRegence FEPRetail ClerksTriCare / TriWestUnited BehavioralUnited HealthcareValue OptionsVirginia MasonWA Basic Health PlanZenith Administrators

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