2008 MEMBERSHIP FORM

An annual full membership in ICSPP includes our peer reviewed journal, Ethical Human Psychology and Psychiatry, our ICSPP Newsletter, and other mailings, and helps us to continue to respond to the hundreds of information queries we receive from the public, the media, and concerned professionals. All members have the satisfaction of supporting our mental health reform efforts as described in our Mission Statement.

Our journal is vital both to those who seek to read, write and publish on issues critical to institutional psychiatry as well as to the life of ICSPP as a scientific and educational institution.

ICSPP is a nonprofit 501 (c)(3) organization. We are a volunteer organization with no officers receiving salaries or other financial benefits.

Name ____________________________________________________________

Address ____________________________________________________________

City ____________________________ State ________ Zip Code______________

Country ______________________________________

E-mail _________________________________ Phone __________________________

Dues for 2008 Check or money order should be made out to: I C S P P

_____ $100 for US residents and $110 U.S. dollars if address is international. Full membership includes a one year subscription (three issues) to our journal, Ethical Human Psychology & Psychiatry, as well as the quarterly ICSPP Newsletter. 

_____$15 for students and for individuals with hardship situations. **

** Please note that members sending less than the full membership amount will not receive our EHPP journal but will receive our newsletter.

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BillingAddress_____________________________________________________

Master Card___ Visa____ American Express____Discover Card____

Expiration Date:__________  Signature:______________________________________

I am also enclosing a tax-deductible donation of $ _________. (A receipt will be sent to you.)

Psychotherapy Referral Source: If you are a licensed clinician who subscribes to the ICSPP philosophy (see our Mission Statement on the ICSPP website) and are interested in receiving referrals, please check here _____ and indicate the state in which you are licensed _______.

Complete this form and credit card info or write check and send to:

 ICSPP - Membership Office
 Dr. Robert Sliclen
 450 Washington Ave
 Twp Of Washington, NJ  07676-4031 U S A