Empezando Contigo: Association for Latine Therapists Membership Application Form

Welcome to Empezando Contigo: Association for Latine Therapists. Join us as we turn our beautiful Networking con Corazón community into this amazing professional association for us! We are honored to have you and look forward to building community contigo.

Nuestra Misión: To center the needs of Latine mental health professionals by providing them with a safe space to make meaningful connections, empower one another, decolonize the mental health field, and uplift the Latine community.

Before completing your application, carefully review the Empezando Contigo: Association for Latine Therapists Membership Description. If you have any questions on the membership or the application, please contact Empezando Contigo: Association for Latine Therapists via email at hola@empezandocontigo.org
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Email *
Membership Description:
Member Commitment:
● Be of Latine (Latino/Latinx) heritage.
● Hold an active independent or associate level licensure in counseling, social work,
marriage and family, psychology, psychiatry, and/or substance use counseling.
● License must be in good standing with the licensing board.
● For associate clinicians, must provide the name, credentials, and contact information for
the licensing board approved clinical supervisor.
● If licensed and practicing outside of the United States, members must provide
verification of licensing equivalence.

Membership Perks:
● Private Facebook group
● Downloadable clinical resources
● Directory listing
● Monthly consultation group
● Monthly support groups
● Monthly virtual networking events*
● Monthly Newsletter
● Frequent in-person networking events (in Phoenix and Long Beach areas as of now)*
● Access to workshops focused on expanding your clinical background and helping your
practice grow
● Advocacy opportunities
● Social media visibility and promotional opportunities
● Public speaking opportunities
● Professional development including but not limited to leadership opportunities
● Career networking including but not limited to mentorship opportunities
*Open to all Latine community clinicians. Paid membership not required.

What we hope to build up to and provide in the future:
● Retreat
● Conference
● Discounted rates on business-related expenses (liability, rental cars, health insurance, legal
support [business, professional will], etc.)
● Monthly in-person networking events*
● Discounted CEU opportunities
1. General Information
Please complete all fields in their entirety.
Membership Type *
First and Last Name *
Preferred Name
Pronouns
Telephone Number *
Email Address *
Tell us why you are interested in joining a Latine-specific professional association.

Please share your reasons for wanting to be part of our comunidad. This helps us understand your goals and how we can best support you.
 *
License Type *
License Number *
State of Issue *
If you are licensed outside of the United States, please provide your licensing country, licensing board, and website.
Additional States with Licensure

License Number(s) in the "Additional States" Listed Above

2. Clinical Supervisor's Contact Information (for Associate Clinicians Only)
If you hold an associate licensure, please complete the following section with your clinical supervisor's contact information.

If you are an independently licensed clinician, please skip and proceed to section 3. Confidentiality and Respecting Boundaries

Clinical Supervisor's First and Last Name

Clinical Supervisor's Telephone Number

Clinical Supervisor's Email Address

Clinical Supervisor's License Type

Clinical Supervisor's License Number

3. Confidentiality and Respecting Boundaries

As members of the Latine mental health community, we recognize that our community is tight-knit and often small. This means we may encounter fellow therapists or clients in both professional and personal settings. To maintain the integrity of our professional relationships and ensure trust within our community, it is essential to uphold strict standards of confidentiality and respect personal boundaries.

As members of Empezando Contigo: Association for Latine Therapists, we commit to:

  • Confidentiality: Protecting the privacy of all clients, colleagues, and members. All information shared in therapeutic or professional contexts must follow HIPAA standards, remaining private and protected, regardless of overlapping roles.
  • Dual Relationships: We recognize the possibility of encountering someone in both therapeutic and professional roles within this community. If a member is both a colleague and a client, we must be mindful of these boundaries, ensuring the integrity of both roles are upheld. This includes refraining from discussing therapy in professional settings unless explicitly agreed upon.
  • Boundaries: Respecting the boundaries of our clients, colleagues, and members, especially in public or personal settings where we may cross paths. This includes maintaining discretion and not acknowledging therapeutic relationships outside of sessions unless the client initiates.
  • Professionalism: Conducting ourselves with cultural sensitivity, respect, and professionalism, recognizing the significance of our roles within the Latine mental health community. We encourage all members to consult their professional code of ethics if they have any concerns regarding dual relationships, boundary issues, or any other concerns.

We understand that upholding these principles not only safeguards our clients' trust but also fosters a supportive and safe space for all members of our community.

4. Consent
By electronically signing below, I confirm that I hold the license(s) stated above and that I am in good standing with my state's and/or multiple states' licensing board(s). 

I certify that all information provided in this application is true and correct to the best of my knowledge.

I consent to the use of my photograph/video and identity on this website and in social media promotion, as appropriate and applicable.

I certify that I have carefully read, understood, agree, and meet all of the requirements listed in the Empezando Contigo: Association for Latine Therapists Member Description and Application forms.
Electronic Signature *
Today's Date *
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Time of Signature *
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6. Next steps:
We will review your application, and if approved, you will receive a Membership subscription link (Paypal). Once your membership payment is completed, we will send you a link to our private Facebook group, details about current membership benefits, and additional resources to help onboard you as a member.

With much gratitude,

Empezando Contigo: Association for Latine Therapists Board Members
7. Terms & Conditions:
Membership Fees Membership is $125/year for general membership. Fees are due annually on your membership start date, at the rate set at that time. You will be notified of any fee increases at least a month in advance. Membership will auto-renew each year for your convenience using the payment method on file. You’ll receive a reminder 14 days prior to your renewal date. To maintain active status, full payment must be submitted on time.  Payment methods we accept: Credit/Debit Cards PayPal Cancellation and Refund Policy You may cancel anytime by emailing hola@empezandocontigo.org. Cancellations must be received at least 30 days before the next billing cycle to avoid charges. Full refunds are issued if cancellation occurs within 5 days of your initial payment. Privacy Policy We value your privacy. All personal and payment information is securely stored and used only for managing your membership. Code of Conduct Members must:
  • Treat fellow members and ECALT staff with respect
  • Follow professional ethical guidelines
  • Engage constructively in association activities
Violations may result in membership termination. Limitation of Liability ECALT is not liable for any damages or losses related to your participation. Membership is undertaken at your own risk. Changes to Terms We may update these terms as needed. You will be notified 14 days in advance. Continued membership implies agreement with the updated terms. Contact Info Questions? Email hola@empezandocontigo.org

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