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Application for Membership
Name:
Name for Directory Listing:
Business Name if different:
Business Address:
Client Contact Phone Number:
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Business E-mail:
Business Website:
Education as listed in Directory:
Certifications and Licensures for listing in the directory:
Memberships and Associations for listing in the directory:
I have read and agree with the Bi-laws, Statement of Faith, Core Values and Ethics Code of the Christian Mental Health Network. I understand that membership is reserved for individuals and organizations who’s professional and personal conduct are consistent with these same values. I agree to adhere to the ethical code and the core values of the CMHN. I certify that the information I have provided to the Christian Mental Health Network (CMHN) is true, correct, and complete. I am not providing misleading, false, or deceptive information. I understand that if I have provided misleading, false, or deceptive information, the network will pursue aggressive legal action. I may be asked to provide additional documentation. I understand that CMHN reserves the right to verify any and all information that I provide. If I misrepresent my credentials, refuse to provide documentation at a later time if asked, or allow my membership with CMHN to lapse, I understand and agree that my membership will be revoked and my membership terminated. If the documentation required for the membership status for which I am applying is not received within 6 months from the date of application, I understand that no refund will be issued in the event of the cancelation or denial of my application. I agree that I will notify CMHN in writing of any civil, criminal, or complaint that is made against me. I agree to hold harmless and indemnify CMHN and its officers, directors, employees, and agents for any misrepresentation of my credentials and for all claims, loss, judgment, or expense. CMHN does not endorse, guarantee, or warrant the work or opinions of any individual members. Membership does not imply licensing or registration by the organization of a member's qualifications, abilities, or expertise. The objective of CMHN's publications and the activities that it sponsors are for informative and educational purposes. The views expressed by the authors, publishers, or presenters are their own views and do not necessarily reflect those of CMHN. CMHN does not assume any responsibility or liability for its members or subscribers' efforts to apply or use the information, suggestions, or recommendations made by the organization, publication resources, or activities. *
Membership Level Requested: Student – must be matriculated in a graduate degree program in a mental health related areas. General – demonstrates interest in one or more of the areas of focus for the Network, but does not necessarily hold employment or licensure in this area. Professional – must have at least a master’s degree in a mental health related area and be in good standing with the issuing agency if they hold a state license.
Please complete the following section if you are interested in having your practice listed in the online Membership Directory. Your listing will be reviewed by CMHN for professional appropriateness before it is listed.
Specialties: (please select up to 8 areas of specialization for your practice):
Please identify the age group(s) to which you provide services:
Please identify the forms of payment you accept:
If you accept insurance for payment please identify those companies for which you are an in-network provider:
Please provide a description of your practice (this will appear in the Counselor Directory as it is written here):
Select Membership Type: (Please note, only the Professional Members will be listed in the online CMHN Find a Counselor Directory)
Word Verification:

When you submit the application, you will be taken to the payment page.

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