Master Therapist Application

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Master Therapist Application

Please complete the application below to apply for the Master Therapist designation. All submitted applications are reviewed and verified. Applicants must be current APA members to be eligible.

After submitting this application, you must forward a copy of your current résumé/vitaé, a copy of your professional license(s), and a copy of any supporting documentation by fax or mail to APA. Please refer to the confirmation page after this application for fax and mail information.

Enter Your Profile Information - Red fields are required

Prefix/Title: (i.e. Dr., Mr., Ms., etc.)

Full Name:

Designation(s):

Suffix: (i.e. Jr., Sr., III, etc.)

Specialty:

Exact Job Title:

Address Line 1:

Address Line 2:

City:

State/Province:

Postal Code:

Office Phone Number:

Country:

Home Phone Number:

Fax Number:

Website:

E-mail Address:

APA Membership

The Master Therapist designation is available to APA members only. Please indicate your Member ID below.

Enter Your Member ID: (Required)

$1250

Master Therapist Designation Certification Fee
The certification fee is one-time only. The Master Therapist designation is valid for the duration of your membership with APA.

If you are licensed, please provide your license number and submit a copy of your license via fax or mail to APA.

License #:

State:

List two professional references. (Required)

Name:	Phone #:
Name:	Phone #:

Please select a specialty area below.

Counselor	Psychotherapist
Psychiatric Nurse	Social Worker
Psychologist	Psychiatrist
Psychoanalyst	Pastoral Counselor
Marriage and Family Therapist	Other

Payment Information

Payment plans are available for this application. A minimum down payment of $250 (non-refundable) must be made with this application and a minimum monthly payment of $100 must be made. Your certificate will be issued upon full payment.

If you do not wish to use the payment plan, then disregard the down payment and monthly payment fields and leave them blank.

Down Payment:
$ .00

Monthly Payment:
$ .00

*Credit Card Type:
*Credit Card Number: no dashes or spaces	*Expiration Date: /

Terms of Agreement

I certify that the above information is true and correct, and I am not misleading or providing false information to the American Psychotherapy Association (APA). I may be asked to provide additional documentation. If I would misrepresent my credentials, refuse to provide documentation at a later time if asked, or allow my membership in the APA to lapse, I understand and agree that my Diplomate status and/or CRS designation will be revoked and my membership terminated. I agree to hold harmless and indemnify the APA and its officers, directors, employees, and agents for any misrepresentations of my credentials and for all claims, loss, damage, judgement, or expense. I certify that I have not been convicted of a felony. I have not been disciplined for any ethical violation in the past 10 years, nor am I under investigation by any legal authority or licensing board.

APA does not endorse, guarantee, or warrant the work or opinions of any individual members. Membership does not imply licensing by the organization of a member's qualifications, abilities, or expertise. The objective of APA's publications and the activities that is sponsors is for educational purposes. The views expressed by the authors, publishers, or presenters are their own and do not necessarily reflect those of APA. APA does not assume any responsibility or liability for its members or subscriber's efforts to apply or utilize the information, suggestions, or recommendations made by the organization, publication resources, or activities.

I certify that I have read the above statement and agree to all of its terms

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American Psychotherapy Association
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Springfield, MO 65804
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