Children's Services Network - Specializing in mental health services for children, teens and families

CHILDREN'S SERVICES NETWORK
MEMBERSHIP APPLICATION

MEMBERSHIP YEAR: _________________

NAME:  ______________________________________________________________________________

DEGREE:  ____________________________________________________________________________

AZ State License #: _____________________________________________________________________

PROFESSION:  ________________________________________________________________________

(Students, please list your school and degree program)

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SPECIALTY:  _________________________________________________________________________

INSURANCE PLANS ACCEPTED (if applicable):  _____________________________________________

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BUSINESS ADDRESS

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PHONE  _____________________________________________________________________________

E-MAIL ADDRESS*  ____________________________________________________________________
*Note: Please be sure to include your email address so that we can add you to the website.

Suggestions for speakers (please volunteer) and topics:  _______________________________________

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FEE: $40 initial fee; $25 for students

Checks may be mailed to:

        Dr. Lanie Zigler
        2633 E. Indian School, Suite 310
        Phoenix AZ 85016
SIGN HERE to indicate your consent to list information in the CSN online directory:

____________________________________________________ DATE: __________________________

BY SIGNING THIS FORM I ATTEST THAT I AM LICENSED IN ARIZONA BY THE APPROPRIATE AGENCY GOVERNING MY PROFESSION AND AM IN GOOD STANDING WITH THIS AGENCY. THE NETWORK NEITHER ENDORSES SPECIFIC PRACTITIONERS NOR VERIFIES CREDENTIALS. THE EXECUTIVE COMMITTEE RESERVES THE RIGHT TO DENY MEMBERSHIP AT THEIR DISCRETION.