Online Application — Central Coast Psychological Association

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P.O. Box 3951

San Luis Obispo, CA 93403-3951

559-284-0897

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Home
2020 Unity Statement
Find a Psychologist
2023 Officers
Membership Marketplace
SLOcal Activities
Members
Contact

Name *

First Name

Last Name

Email Address *

Preferred Mailing Address *

Street or PO Box

City, State Zipcode

Home or Office Address *

Street Address

City , State + Zipcode

Preferred Phone *

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Preferred Fax

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Education *

Psychology License Number *

State of Issue *

Expiration Date

I am a CPA Member

Yes

No

I joined CPA in:

I am an APA Member

yes

no

I joined APA in:

Agreement

I agree that the above information may be published in the CCPA Membership Directory or CCPA Website.

yes

no

Ethics Waiver

Has your psychological practice been restricted, suspended, or in any fashion limited by any hospital, medical staff, licensing body or have you had a formal accusation made by the Board of Psychology or any regulatory body, or have you been convicted of a felony?

yes

no

Code of Ethics Confirmation

I have read and agree to abide by the Code of Ethics of the California Psychological Association. (Note: The Code of Ethics for CPA and other State Psychological Associations is published on the APA Website, located at APA.org.)

yes

no

By endorsing yes, above, you are verifying that you are in compliance with all legal and ethical standards. *

Professional Interests & Responsibilities

Consider being involved in CCPA. Please check your areas of interest from the list below and you will be contacted by member of CCPA:

Ethics

Newsletter

Disaster Response

Continuing Education

Membership

Publicity

Public Interest

Government Affairs

Website

Social

Other Interests

Payment Information *

Member ($80.00)

Life Member ($45.00)

Associate Member ($45.00)

Student Member ($30.00)

Donation to CCPA

Please consider a tax-deductible contribution to help support CCPA.

$

Donation to CPA-PAC

Please consider contributing to the California Psychological Association Political Action Committee (CPA-PAC). The CPA-PAC works with state legislators to help defend and advance the independent practice of psychology in California.

$

Self Disclosure

CPA-PAC donations require that you state your employer, or indicate if you are self employed below:

Thank you for submitting your online form to the California Psychological Association. We are working on developing an online billing system and will let you know when we are prepared to collect your fees electronically.

This form will be forwarded upon receipt to Dr. Bill Safarjan, CCPAMembership Chair.