Update Your Member Information Update Your Member Profile Step 1: You must first select your membership status below BEFORE filling out the rest of the form. Only after choosing your status will you be able to see all relevant fields for you to fill out. Step 2: Proceed to filling out the rest of the form.Select your membership status Clinical Member Associate Clinical Member Affiliate AlumniFirst NameSurnameYou must include an email address here in order to process this profile update request. This email address will NOT be included in your online profile. If you wish to display a contact email address on your profile, be sure to add something in the "Contact Email" field below.EmailUpdate the following fields with your information as you would like it to appear on your Member Profile on the website. To help the website coordinator understand your request, please only fill out fields that you would like to add, change, or remove. If any fields do not apply or are going to stay the same, please leave them blank. If you would like to change fields that are already on your profile, please either: include the whole field with the changes already in it so that they can be easily copied and pasted into your profile (e.g. Your whole biography as you would like it to appear); OR, specify what you would like changed with clear instructions (e.g. please remove "I am from...since 2010" from my biography). ProfessionAre you currently accepting clients? Yes NoHow do you offer services? (select all that apply) Online In Person Telephone Text/EmailBIO (Please note: You must include your profession in the first sentence of your biography)Clients I Work WithServices I OfferLanguagesName of PracticeYour WebsitePhone/Mobile NumberContact Email for Your Online Profile (Optional)Area I Practice In (online? Kanto? Your ward? City?)Address of PracticeAddress Line 1Address Line 2CityPrefecturePostal CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweCost of Services (Please note, the cost of services MUST include taxes. Here are several suggested ways that you write the costs: ◉ ¥11,000 ◉ ¥11,000 (including tax) ◉ ¥10,000 (¥11,000 after tax) ◉ ¥11,000 (¥10,000 before tax) ◉ ¥11,000 (including ¥1,000 tax) ◉ ¥11,000 (¥10,000 without tax plus ¥1,000 tax))Licensure and RegistrationEducation: Please limit to one (1). eg. most recent, most relevant, or highest level of education attained. (eg. BSc Psychology, Cornell University, 2015)Credentials: Please limit to one (1). Type either your most recent, most relevant, or highest level of professional/ occupational credentials that you would like to be displayed (eg. Professional Certified Coach, IFC, 2015). *NOTE: Affiliate members should not use terms that could be confused with clinical or associate clinical members' titles (eg. counsellor, psychotherapist, psychologist etc.).HoursDegree/Education (please write the full name of any degree you want listed: e.g. Master of Counselling (MC))NotesAdditional EducationIf you are an alumni, what was your previous membership status? Clinical Member Associate Clinical Member Affiliate MemberUpload Photo for Your Profile (must be at least 150px wide and 50px tall)Choose File If you have any special instructions for your profile that you would like to give the Website Coordinator, please write them below:Submit Form