Australian Society for Psychological Medicine
Home
About
About the Society
Meet the Committee
Code of Ethics
Membership
Membership Benefits
Join Now
Fellowship
Member Edit My Profile
Member Directory
ASPM Training
Case Consultations
Mental Health Skills Training (Level 1)
Focused Psychological Strategies Skills Training (Level 2)
Mental Health CPD
CCG Area
Events Calendar
Resources
ASPM Newsletters
Websites of Interest
News
Contact
member login
Full Member - Medical Practitioner
ASPM Full Member - Medical Practitioners are entitled to full member benefits and are entitled to vote.
$357.50
Prefix
-
Dr
Assoc Prof
Prof
Hon
Miss
Ms
Mrs
Mr
Cr
DLM
Capt
Sen
Sen The Hon
Hon Dr
Mr and Mrs
First Name
Middle Name
Surname
Gender
--
Male
Female
Non-binary
Prefer not to answer
Date of Birth
Organisation Name
Contact Details
Home Phone
+61
+64
+1
+1
+7
+7
+7
+7
+7
+20
+27
+30
+31
+32
+33
+34
+36
+39
+40
+41
+42
+43
+44
+45
+46
+47
+48
+49
+51
+52
+53
+54
+55
+56
+57
+58
+60
+62
+63
+65
+66
+81
+82
+84
+84
+84
+86
+90
+91
+94
+95
+98
+212
+213
+216
+218
+220
+221
+222
+223
+224
+226
+227
+228
+229
+231
+232
+233
+234
+236
+237
+238
+239
+240
+241
+242
+244
+245
+248
+249
+250
+251
+252
+253
+254
+256
+257
+258
+260
+261
+262
+263
+264
+265
+266
+267
+268
+269
+269
+290
+291
+297
+298
+299
+350
+351
+352
+353
+354
+356
+357
+358
+359
+370
+371
+372
+373
+374
+375
+376
+377
+378
+379
+380
+381
+385
+386
+387
+389
+417
+421
+500
+501
+502
+503
+504
+505
+506
+507
+509
+590
+591
+592
+593
+594
+595
+596
+597
+598
+670
+671
+672
+673
+674
+675
+676
+677
+678
+679
+680
+681
+682
+683
+686
+687
+688
+689
+691
+692
+850
+852
+853
+855
+856
+880
+886
+960
+961
+962
+963
+964
+965
+966
+967
+968
+971
+972
+973
+974
+975
+976
+977
+994
+996
+1242
+1246
+1264
+1268
+1345
+1441
+1473
+1649
+1664
+1758
+1787
+1809
+1809
+1868
+1869
+1876
+7880
+90392
Work Phone
+61
+64
+1
+1
+7
+7
+7
+7
+7
+20
+27
+30
+31
+32
+33
+34
+36
+39
+40
+41
+42
+43
+44
+45
+46
+47
+48
+49
+51
+52
+53
+54
+55
+56
+57
+58
+60
+62
+63
+65
+66
+81
+82
+84
+84
+84
+86
+90
+91
+94
+95
+98
+212
+213
+216
+218
+220
+221
+222
+223
+224
+226
+227
+228
+229
+231
+232
+233
+234
+236
+237
+238
+239
+240
+241
+242
+244
+245
+248
+249
+250
+251
+252
+253
+254
+256
+257
+258
+260
+261
+262
+263
+264
+265
+266
+267
+268
+269
+269
+290
+291
+297
+298
+299
+350
+351
+352
+353
+354
+356
+357
+358
+359
+370
+371
+372
+373
+374
+375
+376
+377
+378
+379
+380
+381
+385
+386
+387
+389
+417
+421
+500
+501
+502
+503
+504
+505
+506
+507
+509
+590
+591
+592
+593
+594
+595
+596
+597
+598
+670
+671
+672
+673
+674
+675
+676
+677
+678
+679
+680
+681
+682
+683
+686
+687
+688
+689
+691
+692
+850
+852
+853
+855
+856
+880
+886
+960
+961
+962
+963
+964
+965
+966
+967
+968
+971
+972
+973
+974
+975
+976
+977
+994
+996
+1242
+1246
+1264
+1268
+1345
+1441
+1473
+1649
+1664
+1758
+1787
+1809
+1809
+1868
+1869
+1876
+7880
+90392
Mobile Phone
+61
+64
+1
+1
+7
+7
+7
+7
+7
+20
+27
+30
+31
+32
+33
+34
+36
+39
+40
+41
+42
+43
+44
+45
+46
+47
+48
+49
+51
+52
+53
+54
+55
+56
+57
+58
+60
+62
+63
+65
+66
+81
+82
+84
+84
+84
+86
+90
+91
+94
+95
+98
+212
+213
+216
+218
+220
+221
+222
+223
+224
+226
+227
+228
+229
+231
+232
+233
+234
+236
+237
+238
+239
+240
+241
+242
+244
+245
+248
+249
+250
+251
+252
+253
+254
+256
+257
+258
+260
+261
+262
+263
+264
+265
+266
+267
+268
+269
+269
+290
+291
+297
+298
+299
+350
+351
+352
+353
+354
+356
+357
+358
+359
+370
+371
+372
+373
+374
+375
+376
+377
+378
+379
+380
+381
+385
+386
+387
+389
+417
+421
+500
+501
+502
+503
+504
+505
+506
+507
+509
+590
+591
+592
+593
+594
+595
+596
+597
+598
+670
+671
+672
+673
+674
+675
+676
+677
+678
+679
+680
+681
+682
+683
+686
+687
+688
+689
+691
+692
+850
+852
+853
+855
+856
+880
+886
+960
+961
+962
+963
+964
+965
+966
+967
+968
+971
+972
+973
+974
+975
+976
+977
+994
+996
+1242
+1246
+1264
+1268
+1345
+1441
+1473
+1649
+1664
+1758
+1787
+1809
+1809
+1868
+1869
+1876
+7880
+90392
Fax
+61
+64
+1
+1
+7
+7
+7
+7
+7
+20
+27
+30
+31
+32
+33
+34
+36
+39
+40
+41
+42
+43
+44
+45
+46
+47
+48
+49
+51
+52
+53
+54
+55
+56
+57
+58
+60
+62
+63
+65
+66
+81
+82
+84
+84
+84
+86
+90
+91
+94
+95
+98
+212
+213
+216
+218
+220
+221
+222
+223
+224
+226
+227
+228
+229
+231
+232
+233
+234
+236
+237
+238
+239
+240
+241
+242
+244
+245
+248
+249
+250
+251
+252
+253
+254
+256
+257
+258
+260
+261
+262
+263
+264
+265
+266
+267
+268
+269
+269
+290
+291
+297
+298
+299
+350
+351
+352
+353
+354
+356
+357
+358
+359
+370
+371
+372
+373
+374
+375
+376
+377
+378
+379
+380
+381
+385
+386
+387
+389
+417
+421
+500
+501
+502
+503
+504
+505
+506
+507
+509
+590
+591
+592
+593
+594
+595
+596
+597
+598
+670
+671
+672
+673
+674
+675
+676
+677
+678
+679
+680
+681
+682
+683
+686
+687
+688
+689
+691
+692
+850
+852
+853
+855
+856
+880
+886
+960
+961
+962
+963
+964
+965
+966
+967
+968
+971
+972
+973
+974
+975
+976
+977
+994
+996
+1242
+1246
+1264
+1268
+1345
+1441
+1473
+1649
+1664
+1758
+1787
+1809
+1809
+1868
+1869
+1876
+7880
+90392
Email Address
Send correspondence to this address
Secondary Email
Send correspondence to this address
Primary Address
Home Address
Work Address
This is your mailing address. Print mail is sent to this address.
Addresses
Home Address
Work Address
Address 1
Suburb / Town
Postcode
State
-- select country below to see states --
Country
--
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia And Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Columbia
Comoros
Congo
Costa Rica
Cote D'ivoire (Ivory Coast)
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kirabati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Laos, Peoples Democratic Republic of
Latvia
Lebanon
Lesotho
Liberia
Liby An Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macedonia, The Former Republic of Yugoslavia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, (Federated States of)
Moldova, Republic of
Monaco
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
Saint Lucia
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Helena
St.Kitts & Nevis
St.Vincent
Sudan
Suriname
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvula
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Save Changes
Address 2
Suburb / Town
Postcode
State
-- select country below to see states --
Country
--
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia And Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Columbia
Comoros
Congo
Costa Rica
Cote D'ivoire (Ivory Coast)
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kirabati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Laos, Peoples Democratic Republic of
Latvia
Lebanon
Lesotho
Liberia
Liby An Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macedonia, The Former Republic of Yugoslavia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, (Federated States of)
Moldova, Republic of
Monaco
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
Saint Lucia
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Helena
St.Kitts & Nevis
St.Vincent
Sudan
Suriname
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvula
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Save Changes
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)
Delete
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
How did you hear about ASPM?
Payment
Fees Due
Membership Fee:
complete home address to see fee
Discount Code
IMPORTANT NOTE: The first instalment payment for your membership, and payment for any selected membership add-ons and joining fees, will be deducted immediately.
Payment Method
Card
Cheque/EFT
Card Type
Visa
Mastercard
Name on Card
Card Number
Card Expiry
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
YY
21
22
23
24
25
26
27
28
29
30
31
Account Name
BSB
Account Number
Important!
Your application will not be confirmed until payment has been received by Head Office.
On completion of this registration an invoice will be emailed to you. Please follow the payment instructions on the invoice to finalize payment.
It looks like you haven't completed your Primary Address.
Submit Application