HOUSTON PSYCHOANALYTIC SOCIETY / 900 LOVETT BOULEVARD, HOUSTON, TEXAS 77006

www.houstonpsychoanalytic.org

Houston Psychoanalytic Society

Annual Dues Statement 2012-2013
The Houston Psychoanalytic Society (HPS) dues year begins July 1st of each calendar year. Please
select one of the three membership levels (see table below) and complete the required information.
Please note the following:
All members pay a reduced fee if paying before October 1, 2012.
Membership Dues Amounts
Membership
Level
Active
Student
Friend

Before 10/1/12
$180
$35
$90

On/after10/1/12
$200
$45
$100

Membership Benefits
Active Member:
2 hours CEU for each monthly meeting
3-hour ethics course (free)
Reduced fees at workshops
Business meetings with dinner or reception
Opportunity to vote and hold office
Listing in Membership Directory with contact information and areas of specialty
Ability to network using online HPS Message Board
Student Member:
Must be a full-time student
Same benefits as Active Member
Friend:
2 hours CEU for each monthly meeting; $20 charge per meeting
Reduced fees at workshops
Please contact Ruth Rosines at membership@houstonpsychoanalytic.org with any questions
regarding membership.

Contact Information
Name:

__________________________________________________________________________________________________________________________________________

Check membership level:

Active
Student
Friend
Would you consider making a contribution of $10 or more to further support the work of HGPS?
Dues Paid______

Contribution_______ Total Paid_______

List educational institution if applying for student membership:

_________________________________________________________________________________________________________________________________________________________________
Licensure: ________________________________________________________________________________________________________________________________________________
Office Address: _______________________________________________________________________________________________________________________________________
City __________________________ State ___________ Zip ___________________________________________________________________________________________________
Phone: _____________________Alternate Phone: ____________________________________________________________________________________________________
E-mail:______________________________________________________________________________________________________________________________________________________
Website:___________________________________________________________________________
In order to comply with the Bylaws of the American Psychoanalytic Association, answers to the
following ethics questions are required:
For New Members:
(1) If you hold a license to practice, has your license ever been suspended, revoked, or limited by a
state licensing board?
Yes______ No______
(2) Have you ever been convicted of a felony?
Yes______ No______
For Renewing Members:
(1) In the past 12 months, if you hold a license to practice, has your license been suspended,
revoked, or limited by a state licensing board?
Yes______ No______
(2) In the past 12 months, have you been convicted of a felony?
Yes______ No______
If your answer to any of the above questions is yes, please give a detailed explanation in the space
provided below.
_________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
Are you a member of the American Psychoanalytic Association?

Yes______ No______

Check here if you would be interested in helping with new HPS members.

An online Membership Directory listing Active members and Students will include name, address,
phone number, e-mail address, populations served, and three areas of specialization. To be listed in
the Directory, dues must be paid before October 1, 2011.
Check here if you do not want your e-mail address included in the Directory.
Check here if you do NOT want to be listed in the Directory.
If you do want to be included in the online Membership Directory, please check the populations you
serve and three (3) areas of specialization from the following menu:
Population(s) Served (Choose 3):
___Child
___Family
___Adolescent
___Couples
Specialty Areas (Choose 3):
___Abuse
___Addictions
___Aging Issues
___Anxiety/Phobias
___Anger Issues
___Bipolar Disorder
___Compulsive Disorders
___Depression
___Developmental Disorders

___Elderly
___Adult

___Groups

___Eating Disorders
___Evaluations/Assessments
___Grief
___Marriage/Relationships
___Parenting Issues
___Personality Disorders
___Post Trauma Stress Disorder
___Psychoanalysis
___Trauma

___Other_________________________________
___Other_________________________________
Members are responsible for the accuracy of their information. For corrections please contact
admin@houstonpsychoanalytic.org.