Virginia Association of Clinical Counselors

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Membership Type *	BUILDING A POWERHOUSE PRACTICE ($95.00 for period 04/29/2010 - 04/29/2010) Event date pending. BUILDING A POWERHOUSE PRACTICE ($75.00 for period 04/29/2010 - 04/29/2010) Event date pending. Still accepting registrations! Clinical- 1 Year ($65.00 for one year) Masters Degree or higher in counseling or a related field that covers the basic principals of Mental Health Counseling OR State license as a Licensed Professional Counselor Clinical- 2 Years ($130.00 for 2 years) Clinical- 3 Years ($195.00 for 3 years) Student- 1 Year ($20.00 for one year) Enrolled at least half-time in a graduate program in counseling or a related discipline. Regular- 1 Year ($65.00 for one year) Unlicensed, Masters Degree or higher in counseling or a related field Retired- 1 Year ($25.00 for one year) Completely retired from mental health profession
Payment System *	Credit Card (PayPal) secure credit card payment Check or Money Order Check or Money Order
Your Name * Your First & Last name
Your E-Mail Address * A confirmation email will be sent to you at this address
Choose a Login Name (User ID) * It must be 4 or more characters in length and may only contain small letters, numbers, and the underscore '_'
Choose a Password * Must be 4 or more characters
Confirm your password * Enter password again
Practice Name
Address * Your Mailing Address
City *
State *
Zip Code *
Home or Cell Phone # Insert either your home or mobile telephone number.
Office Phone #
Fax Number
Website
License Number
Degree's	LPC LMFT MA Ed.D NCC PhD CSAC Other
Practice Setting	Church Community Mental Health EAP Government Agency HMO Home based Hospital Inactive Inpatient Private Agency Private Practice University
Insurance Accepted
Theory and Techniques Hold down the CTRL key as you click to select multiples.
Population	Adolescents Adults Children Christian College Students Couples Cross-Cultural Elderly Families Gay/Lesbian/Bisexual/Trans Groups Men Staff/Org. Development Training/Public Speaking Women
Languages Languages spoken besides english	American Sign Language Arabic Bengali Cantonese Farsi French German Hebrew Hindi Italian Japanese Korean Mandarin Portuguese Punjabi Russian Singales Spanish Tagalog Urdu
Offer Supervision To be included in the supervision list select one or more.	Individual Group Mentor
Personal Statement Recommend including special training, special certification, factors unique to you and your practice.