IMHPJ Membership Application Form

You have moved to IMHPJ On-Line Application Form.
Please click on "Submit This Application" button, at the top-right or bottom-right corner,
when you finish filling in all your profile data and ready to submit the application.

  Mandatory fields

Basic Information
Category of Membership
Member Name
Family,Given NameMiddle
,
Photo

Degree(s)
PhDMAMS
MSWMA PsychEdD
MScPsychMD
Other:
Profession
Clinical PsychologistPsychologist
Child PsychologistCounseling Psychologist
Social WorkerClinical Social Worker
CounselorPsychiatrist
School CounselorSchool Psychologist
Family TherapistPsychotherapist
Other:
Contact Telephone Number
Area Code Number
-
* For outside Japan number, include Country Code in Area Code text field
Fax Number
Area Code Number
-
Contact E-mail
* Enter "None", if you do not have email for this time.
Notes
* If you would like to include any additional information
(especially about your contacts), please fill in here.
(i.e. Cell phone numbers, convenient time for clients to reach by phone, etc.)
Service Information
Services Offered
Individual PsychotherapyCouple Therapy
Group TherapyFamily Therapy
Individual CounselingSeminars and Workshops
Clinical Supervision
Parenting Educational/Counseling
Psycho-Social-Educational Assessments
Psychological Assessments
Medication Evaluation and Manag
Informational and Referral
ConsultationPhone Counseling
Internet Counseling
Psychiatric Assessment and Treatment
Other:
Populations Served
AdultsAdolescentsChildren
Older AdultsWomenMen
StudentsGay/LesbianReturnees
Languages Spoken
Services provided in: EnglishJapanese
DutchGermanFrenchSpanish
ChineseKoreanTagalogHindi
Other:
Practice/Organization Name
Work Address
(Main location)		 * Leave it blank if none applies or do not want it to appear in your profile.
Street
Apt./Building
City/Ward
Prefecture/Area
Postal Code/Zip Code
Country*
(*Enter "Country" only if it is an ouside Japan address.)
Work Address
(If there are other Work/Practice locations, fill in here.)
 * Leave it blank if none applies or do not want it to appear in your profile.
Street
Apt./Building
City/Ward
Prefecture/Area
Postal Code/Zip Code
Country*
(*Enter "Country" only if it is an ouside Japan address.)
Work Address
(If there are other Work/Practice locations, fill in here.)
 * Leave it blank if none applies or do not want it to appear in your profile.
Street
Apt./Building
City/Ward
Prefecture/Area
Postal Code/Zip Code
Country*
(*Enter "Country" only if it is an ouside Japan address.)
Website URL
Nearest Train Station / Map image Briefly explain direction to your office. (1000 characters max.)
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You can upload a map image!
Work/Office Hours Currently accepting clients. (200 characters max.)
Hours:
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Closed:
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Usual Vacation Times:

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Fee Ranges (800 characters max.)

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Arrival Date in Japan
Arrival Date in Japan:
Estimated Departure Date:
Other Detailed Information
Degrees (detail) Degree/Subject/Institution/Location/Date (600 characters max.)

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State/Federal Licenses State/Country/Name of Licence/Licence Number/Initial Licence Date (600 characters max.)

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Professional Registrations Acronym/Full Name of Professional Body/Registration Category/
Initial Registration Date (600 characters max.)

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Additional Training/Internship/Work History Type of Training/Internship/Work Location/Date (1000 characters max.)

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Areas of Special Expertise Length and Type of Work Experience (1000 characters max.)

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Note to IMHPJ
(For communication use only)		 (800 characters max.)

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