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National Anger Management Specialist Directory Anger Management Specialist Certification Trainings Anger Management Training for Professionals |
MEMBERSHIP APPLICATION
Print Application
Title:_____ First Name:_____________________ Middle Initial:___ Last Name:___________________________________________(include professional degree) (Agency or Affiliation if Applicable):_______________________________________________________________ Street Address:____________________________________________________________ City_____________________________________ State:_________________ Zip Code:_______ Please indicate whether the address above is your:___ Home Address or ___ Business Address Daytime Phone:____________________ Fax :_____________________ Email :______________________________ Repeat Email ______________________________ Please enter Email address carefully. We will use it to send confirmation of your application. PROFESSIONAL BACKGROUND In order for your application to be processed, you must answer ALL questions COMPLETELY 1. Type of Credentials:___RN ___LPC ___LSW ___LCSW ___LMFT ___PhD ___MD ___ Other - Please specify______________ License No. (If applicable) ______________ State _______ 2. How many years of experience do you have in providing anger management services?:_______3. With how many clients are you currently working?____ 1-10 ___ 11-20 ___ 21-30 ___ 30 or more4. Years of experience providing anger management service:___ 1-3 ___ 4-6 ___ 7-10 ___10 or more5. Please check all areas of interest for future trainings. (You may check multiple fields)___ Anger Management Updates in Treatment ___ Couples Anger Management ___ Children & Anger ___Group Work ___ Adolescent Anger Management ___ Parenting & Anger ___ Other:_______________________________________________ 6. Would you be willing to provide outcome survey information measuring benefits of your work? ___ Yes ___ No7. Please indicate if you work for:____ Agency ____ Private Practice 8. Are you willing to volunteer to provide time and leadership for NAMA?___ Yes ___ NoPlease Specify:________________________________________________________________________ 9. How did you hear about NAMA?___ NAMA Website ___ Direct Mailing ___ Email ___ Professional Journal ___ Word of Mouth ___ Other - Please specify____________________________________________________ 10. Please include one copy of your Resume or CV with this application.11. Which Membership Level are you applying: (One year dues covers application fee & first year membership)__Professional Level __Fellow Level __ Diplomate Level __Student Level __Agency (Dues: $75/yr) Dues: $100/yr) Dues: $200/yr) (Dues: $25/yr) ( Contact the NAMA office)mailto:namass@namass.org Checks payable to: NAMA, 2753 Broadway Suite 395, New York, NY 10025
Contact Information
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Distinguished Diplomates Charles Spielberger, PhD Ronald Potter-Efron, PhD Patricia Potter-Effron, MS Richard Pfeiffer, MDiv, PhD Anita Bohenksy, PhD Matthew McKay, PhD Harriet Lerner, PhD William Fleeman
Board of Directors Richard Pfeiffer, MDiv, PhD President Al Johnson, MD Past President Stephen Spiller, Esq. Rhoda Urman, LCSW Jennifer Roberts, LCSW Terrence Williams, PhD, MD
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