Name *

First Name

Last Name

Phone *

(###)

###

####

Type of Membership *

General Member - Psychiatrist in North America

Liaison Member - Non-psychiatrist, e.g., psychologist, psychiatric nurse practitioner or PA, social worker, etc.

International Member - Psychiatrist or Liaison member outside of North America

Member In Training - Medical student

Member In Training - Resident or Fellow

In what setting do you currently work/practice? *

Academia

Administration/Management

Assertive Community Treatment Team

Community mental health center

Consultant

Federal government / VA

Federally qualified health center or other setting integrated with primary care

Inpatient hospital unit

Jail/Prison

Outpatient clinic

Outpatient Addictions Program

Private Practice

Short term residential crisis center

Residential treatment

Other

Management/ Leadership role

What is your profession? *

Doctor of Medicine

Doctor of Osteopathic Medicine

Counseling professional

Psychiatric Nurse Practitioner

Psychologist

Social Worker

Other

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Would you like for the AACP to use some of the information in this form to create a Member Directory entry for you? This directory will only be accessible by fellow AACP members only. You will be able to update your directory entry in the member portal at any time. *

Yes

No

**For Members in Training: Please indicate your training level

Medical School

Residency

Fellowship