Student Application

Student Member Application

"*" indicates required fields

Date*

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Email*

Graduate School Affiliation*

Membership Fee*

Price:

Total

Credit Card

Configuration Required: To use the Square field, please configure your Square Settings.

If you are a therapist hoping to learn more about cutting edge therapy, or a potential client looking for highly effective therapy for yourself, your relationship, or your family, you’ve come to the right place!