Australian Society for Psychological Medicine

Prefix

First Name

Middle Name

Surname

Gender

Date of Birth

Organisation Name

Contact Details

Home Phone

Work Phone

Mobile Phone

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Email Address

Send correspondence to this address

Secondary Email

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Primary Address

This is your mailing address. Print mail is sent to this address.

Addresses

Home Address
Work Address

Address 1

Suburb / Town

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Country

Address 2

Suburb / Town

Postcode

State

Country

Primary Medical Qualifications (Please provide full name of any degree or diploma, institution and year of graduation)

Other undergraduate qualifications (Please provide full name of any degree or diploma, institution and year of graduation)

Postgraduate qualifications (Please provide full name of any degree or diploma, institution and year of graduation)

RACGP/ACRRM Number (if applicable)

AHPRA Number

Practice Type

General Practice

Psychological Medicine Practice

Mixed Practice (General & Psychological)

Solo Practice

Group Practice

Practice Setting

Private

Community Clinic

Hospital

Other

Clinical interests

Trauma-specific Therapy

Eating Disorders

Family Therapy

Relationship Therapy

Children and Adolescents

Geriatric Care

EMDR

Sensorimotor Therapy

Hypnotherapy

Approximate hours worked (including hours spent in psychological medicine)

Languages spoken

I am interested in participating in the following Society activities:

No Activity

Management Committee

Newsletter

Lobbying

Website

Continuing Education

Marketing/Promotions

Include in Member Directory?

Yes

No

Member Profile for Directory (max 150 words)

Directory Image (max size 1 Mb)

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Do you have Prior Training in FPS Level 1 or 2?

Yes

No

Prior Training in FPS Level 1 or 2 - please advise level held, year completed and training provider

Payment

Fees Due

Membership Fee:	complete home address to see fee

Discount Code

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Card Number

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