New Member Application

Clinical Membership in the Guild is open to professionals engaged in the conduct of psychotherapy on Bainbridge Island. Members who join after January 15, 2007 must be licensed mental health professionals in the State of Washington who have earned a minimum of a Master’s degree in one of the established mental health disciplines from an accredited college, university, or professional training program (including, but not limited to psychiatry, clinical or counseling psychology, clinical social work, marriage and family therapy, and mental health counseling).

The fee for clinical membership is $60.00. For payment options please see our Membership page.

Additionally, a scanned copy of your City of Bainbridge Island Business License should be sent to infoatbipg@gmail.com.

 

Application for clinical membership:

    * Indicates a required field.

    First Name*

    Middle/Init

    Last Name*

    Primary Work Address*

    City/State/Zip*

    Second Address

    City/State/Zip

    Primary Phone (for publication)*

    Secondary Phone (for publication)

    Email*

    Website URL

    License Number:

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

    Credentials*Check as many as apply

    Practice Name

    Description of Your Practice*

    Notify me of routine Guild business via*

    Issues and Concerns*

    If a specialty of yours is not listed, we recommend that you mention the specialty area in the “description of your practice” above.

    Treatment Modalities*Check as many as apply

    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

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

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