Name (Last, First, Middle) & degrees or certifications:

Home address:

Home phone:

Home fax:

Work (Name and address):

Work phone:

Work fax:

E-mail (main):

Please retype main email address:

Alternative e-mail if available:

Please retype alternative e-mail address:

Therapeutic Approach:

Training and experience in group psychotherapy and/or group processes:

Membership in other professional organizations:

Please give name and contact details of a sponsor from IAGP or another professional with whom you have been working regarding your group work.

Comments:

IMPORTANT: After submitting this application form you will have the option to proceed directly to the IAGP's 2009-2012 registration and payment form. If your application to join IAGP is not successful, your credit card will not be billed.