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* 1. First Name

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* 2. Last Name

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* 3. Degree or license (Psy.D, LICSW, etc)

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* 4. Street

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* 5. City

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* 6. State

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* 7. Zip Code

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* 8. Phone

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* 9. Email

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* 10. Select a total of 5 specialties - 5 only!!

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* 11. Do you want to utilize any of these resources:

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* 12. What town is your office in? 

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* 13. What language(s) can you work in in addition to english?

MIP’s Board of Directors has instituted a policy whereby members and applicants for membership are obliged to inform the President of all ethical complaints, investigations or findings of ethical violations regarding their clinical practice. Do NOT use this form for such a disclosure, please contact the president of MIP about any disclosure. The Board anticipates and expects that MIP members will adhere to the ethical code of their respective professional organizations. The Ethics Committee of MIP created the following statement with the approval of the Board:

Each member, candidate, fellow or applicant to become a member, candidate or fellow of MIP has an affirmative obligation to inform the President of MIP of whether he or she:

i.  Has been sanctioned or dismissed by any hospital, mental health organization, or professional organization for ethical violations, or has voluntarily resigned from a professional organization in response to an investigation of ethical conduct or

ii.  Has had his or her professional license revoked or suspended or has otherwise been disciplined by any professional organization or licensing board for ethical violations or

iii.  Has been refused malpractice insurance or has had any such insurance policy cancelled or

iv.  Is subject to an investigation pertaining to any of the situations referred to in items i-iii above.

v.  The above obligation continues for the duration of the person’s affiliation with MIP.  Any change with respect to items i-iv shall be reported promptly to the President of MIP.

It has been previously established that any person serving as a supervisor, faculty or member of the Board of Directors must be a member of MIP.

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* 14. I have read the ethics attestation

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* 15. I affirm I am not currently involved or have ever been involved in any of the issues identified in items i. - iv. in the above statement other than what I have disclosed pursuant thereto.

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* 16. I understand the above obligation continues for the duration of my affiliation with MIP. Any change with respect to items i-iv shall be reported promptly to the President of MIP. I also understand that this form must be completed on an annual basis.

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* 17. My full name

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* 18. Dues Payment method

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