Membership Update Form As part of our modernization efforts the USABP has now upgraded to a new membership database system. Thank you for taking the time to tell us about you and update our records! Email* First Name* Last Name* Title* Company Address 1* Address 2 City* State* Zip* Country* Phone* Website Gender* ChooseFemaleMaleTransgender Birthday (MM-DD-YYYY) JanFebMarAprMayJunJulAugSepOctNovDec 01020304050607080910111213141516171819202122232425262728293031 1910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 Bio Accepts Insurance Yes No Alternative Languages Yes No Avg Cost (per session) Certification Company or Individual Company individual Degree/Designation Gay/Lesbian Focus Yes No Gender Treatment Specialty Yes No Graduation Date Instituional Role Board Member Faculty Research Committee Journal Author Other NA Mental Health License Mental Health Profession Med License Membership Directory Opt In Opt Out Physical License Practice Description Professional Affiliations Referring Member School/Certification Sliding Scale Yes No Specialties Web Address Willing to Volunteer Yes No Years in Practice Less Than 5 5 to 10 10 to 15 15 to 20 20 years plus Age Group Child Adolescent Adult 18 – 25 Adult 26 – 35 Adult 40 – 65 Adult 65 + * required information
