Apply for Membership - Online Application - International Mental Health Professionals Japan

Membership Application

IMHPJ is a voluntary association of professionals and is not a licensing body. Membership is divided into four categories: Clinical, Associate Clinical, Affiliate and Overseas Alumni. Please use the following information to determine the category for which you qualify.

How did you hear about IMHPJ?

For which category are you applying?*

Clinical Member
Associate Clinical Member
Affiliate Member
Overseas Alum Member

If you are applying for Overseas Alumni, when was the last year you were a member?

Confidential Information

The information you provide on this form is used only: 1) to verify your qualifications 2) to certify your membership level; and 3) to communicate among IMHPJ members regarding IMHPJ-related matters. Your information will not be used for any other purpose and will not be shared with any 3rd parties.

Member Name*

First Last

Email*

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Name of Practice

Work Address (Address of Practice)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Work Email

Website

Acedemic Degree, Licensure & Registration

All applicants should list academic degrees with dates of completion and places of study. Please upload photocopies below. (If you are also licensed or registered in your home country, please provide license/registration numbers, photocopies and website addresses to verify their current status, etc.)

Additional Education and Certifications

Upload photocopies here

Drop files here or

If you are applying for Clincial Membership

If you are applying for Clinical Membership, has your training included 2500 clinical hours with at least 250 hours of direct supervision?

YES
NO

NOTE: There are several ways to assist us to verify your training experience and credentials: 1) With website info and a copy of a license or registration. 2) Or, with official document copies that show your hours of clinical work with hours of supervision. 3) Or, with a letter detailing how you meet the criteria above, with verifiable data, wherever possible.

If you are applying for Associate Clinical Membership

If you are applying for Associate Clinical Membership, please tell us about your clinical experience and supervision, and provide evidence. Please see the NOTE above regarding verifying clinical experience for reference.

Are you currently receiving supervision?

If so, will you give us more details with contact information?

Do you have any history of legal convictions in Japan or any other country?

YES
NO

If yes, please explain.

Have you ever lost your professional license, been subject to disciplinary action by your licensing organization (including any pending or ongoing professional reviews that might limit or revoke your license to practice)?

YES
NO

If yes, please explain.

Are you currently accepting clients?

Yes
No

Do you want to be listed on our website as such if invited to become a member?

Yes
No

If applying to become an Affiliate Member

If applying to become an Affiliate Member, please tell us about yourself and your interest in IMHPJ. Please attach documents, wherever possible, to verify education, any licenses, if listed.

Do you plan to reside in Japan at least 8 months of the year for which you’re applying?

Yes
No

NOTE: In order to be listed publicly on our website and in other directories, photocopies of all relevant academic degrees, licenses, registrations, and professional organization memberships must be included with this application, with translations if necessary.

Consent*

I have read and agree to abide by the IMHPJ Constitution and IMHPJ Code of Ethics.

Date*

Signature*

Your signature here indicates that you meet the requirements for the membership category for which you’re applying.

Apply for Membership – Online Application

Membership Application

Membership Application

Confidential Information