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 $60 and email your current City of Bainbridge Island Business License to infoatbipg@gmail.com  (see Membership page for payment options).

 

    * Indicates a required field.

    First Name*

    Middle/Init

    Last Name*

    Email*

    Only complete those fields below that have changed. You will need to upload your business license in order to complete this form.

    Primary Work Address

    City/State/Zip

    Second Address

    City/State/Zip

    Primary Phone (for publication)

    Secondary Phone (for publication)

    Website URL

    License Number:

    Supervisor name, credential, license number (if applicable):

    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

    AdolescentsAdultsChildrenCouplesFamiliesGeriatricsLGBTQIA+

    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

    Comments:

    Upload a copy of your business license (1MB max, .jpg or PDF format)*:

    Upload a profile photo (1MB max, .jpg format) for publication:

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