2023 Membership Renewal

Please update the following information for our records, complete the annual attestation, and submit your payment for your annual dues. Thank you for your cooperation and continued support. NOTE: This form is only for returning members, for new members please visit: https://fs8.formsite.com/PeterDodzik/b48gerxt5i/index.html

Profile Update

If any of the following information has changed, please type your updated information in the respected category.
Board Certifications
 

Membership Categories

Choose one Membership Category (Apply for the highest category to which you are entitled).  
 
Membership Category (Choose only one) (Please do NOT complete this form If you are a new member) *
Areas of Interest
 
Other Related Professional Affiliations
 

Annual Attestation - Required

If you are a student, click NO for all attestation questions.
 
Please answer the following questions regarding the past year:
Has your professional liability insurance ever been terminated by action of an insurance company? *
Have you been denied professional liability insurance coverage or rated in a higher than average risk class for your professional specialty? *
Have any disciplinary actions ever been initiated and/or are any pending now against you by any state licensing board, whether or not you were a member of the professional standards board initiating said action? *
Has your license to practice psychology in any state been denied, limited, suspended, revoked or voluntarily relinquished? *
Have you ever been suspended, sanctioned, or otherwise restricted from participating in any private, federal, or state health insurance program (for example, Medicare, Medicaid, or any managed care company)? *
Have you been the subject of an investigation by any state, federal, or private agency concerning your participation in any state, federal, or private, health insurance program? *
Has your application for appointment or reappointment, or your privileges at any hospital or other health care facility ever been denied, reduced, suspended or not renewed? *
Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings in any professional organization? *
Have any professional liability claims, suits, or judgments ever been made against you or are such claims, suits, or judgments currently pending or have you ever been made aware that any will be filed? *
Have you ever been convicted of a felony or misdemeanor other than minor traffic violations? *
Have you ever had, or are you currently aware of having any physical, mental or emotional condition, or chemical dependency/substance abuse problem which may interfere with your ability to care for patients in any way? *
If any of your answers were YES to any of the questions above, please provide detailed information below.

Signature: I certify that all of the information provided herein is accurate. I understand and agree that if any of the information I have provided is proven to be false or misleading, if in the future my behavior results in the probation or suspension of my license, or I become the subject of an ethics investigation on the part of the APA or my State Psychological Association, my membership or board certification status may be suspended or revoked. I agree to use my credentials appropriately and will not use the ABPdN credentials or any other credentials that I might have to mislead consumers or colleagues to believe that I have been trained or examined in areas other than that specified. I understand that to retain my board certification, if attained, I must be licensed to practice at the independent level as defined in the ABPdN bylaws. Please type your name as your signature. *
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