BPA Membership Application 2024
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Email *
Renewal membership or New member  *
Last Name *
First Name *
Contact Information
Full Address
House Number and Street (ex. 85 Cricket Drive) *
Apt/Ste #
City *
State *
Zip Code *
Work Address (Street address, ex: 1022 Linden Street)
Line 2 of Work Address, if needed
Apt/Suite #
City
State
Zip Code
Home/Cell Phone # (XXX-XXX-XXXX) *
Work Phone # (XXX-XXX-XXXX)
Professional Information
Type of Degree (Check all that apply) *
Required
If you answered other above, please specify additional degrees
University where you obtained your highest degree *
Date of Highest Degree (Month, Year) *
Type of License or Certification (check all that apply) *
Required
If you answered other above, please specify type of certification or license
States where you are licensed or certified (check all that apply) *
Required
If you answered other above, please specify additional states where you are certified or licensed
Maryland License/Certificate # *
Other State License/Certification # (per state)
Are you authorized to practice under PSYPACT?
Clear selection
Does your mental health practice accept medical insurance?
Clear selection

Type of Practice or Position (Check all that apply)

 *
Required
If you answered other above, please specify the type of practice or position 
Specialty Areas?

Future Presentations:  Presenters are eligible for up to nine (9) continuing education units (CEUs).  Are there topics you are experienced with and willing to present in the coming year?  

Do you know a person who would be a good speaker for BPA?  Please include their name, email address and area of specialty. 
Do you authorize BPA to send you emails?  *
Do you consent for BPA to publish your name and contact information in a (members only) Membership Directory
 *
New Members Only: How did you hear about BPA? Check all that apply:
Do you have a friend or colleague you would like to refer to BPA?  Please include their name, email address, degree and/or type of licensure. 
Are you interested in being on a BPA committee? (Check all that you are interested in.)
In which of the following BPA Executive Board positions are you interested? 
If you answered other above, please specify the other position in which you are interested.

Membership Category:  (Check the one that applies)

 *
Students must be currently enrolled in an academic program and need to send an email using their university email to baltimorepsychassociation@gmail.com and attach a copy of their student ID.
Do you acknowledge that all the information is true and correct to the best of your knowledge:
 *
Pay membership dues by Venmo
@baltpsychassoc
Or, make checks payable to “BPA” and send to:

Lynda Payne
1796 Indian River Road
Virginia Beach, VA 23456
BPA requires reimbursement of all charges if check is not honored by applicant’s bank
For questions contact Dr. Barbara Baum, PhD at barbarabaum506@yahoo.com or Dr. Cindy Hunter at cindybethhunter@gmail.com 
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