Member Signup

We are pleased you are considering applying for membership in the Psychoanalytic Center of the Carolinas. The PCC has 2 categories of membership:

Professional Members
Community Members

Community membership is for persons without clinical training wishing to participate in our organization.

Member Pricing *

Professional($200 - Q2 Prorated: $50)($150 - Q2 Prorated: $37.5) - $ 112.50 (includes Sales Tax of $ 0.00)

Community($50 - Q2 Prorated: $12.5)($38 - Q2 Prorated: $9.375) - $ 28.13 (includes Sales Tax of $ 0.00)

I would like to enroll in the PCC's groups subscription to the
Psychoanalytic Electronic Publishing website (PEP-Web)
at the discounted rate of $71/year.

PEP-Web subscription

PEP-Web subscription - $ 71.00 (includes Sales Tax of $ 0.00)

Total Amount

Name and Address

Prefix

First Name *

Last Name *

Suffix

Street Address (Main) *

City (Main) *

State (Main) *

Postal Code (Main) *

Country (Main)

Phone *

Email *

Nickname/Preferred Name

Partner/Significant Other

Pronouns

Occupation

Additional Information

Psychoanalytic Training

Name of Institution

Location

Training Track/Course of Study

Adult/Child Integrated Adult Psychoanalysis Child Psychoanalysis Psychoanalytic Psychotherapy Other

Year of Graduation (YYYY)

Non-Graduate/Current Trainee Comments (optional)

Clinical Information

Accepting New Patient? *

Yes No

Checking "Yes" will include your profile in the PCC's public Therapist Search

License

(E.g., LCSW, MD, etc. Enter n/a if not applicable)

APsaA Member

Yes No

Website

Accepted Payment Methods

Cash

Check

Credit Card

Client Focus

Toddlers / Preschoolers (0 to 6)	Children (6 to 10)	Preteens/Tweens (11 to 13)
Adolescents/Teenagers (14 to 19)	Adults	Elders (65+)

Insurance

Aetna

BCBS

Cigna

Humana

Medcost

Medicaid

Medicare

Out of Network

United

Sliding Scale

Yes No

Treatment Modality

Individuals

Couples

Family

Group

Treatment Orientation

Education

College/University

Degree

Other

Course of Study

An introduction to be shared in the public Therapist Search and Membership Directory

About

Areas of Interest

Each member of the PCC is encouraged to use their unique talents in promoting the organization's charitable and educational purposes of increasing awareness of mental health in the community. Members can do so by serving in the PCC through volunteering, engaging in committee work, and/or participating in several aspects of membership and governance of the organization. In this way, membership is a rewarding and long-term commitment.

Please let us know if you are interested in learning about the following PCC efforts:

Areas of Interest:

Communications/Marketing Fundraising Psychoanalytic Training and Education Programs Faculty Anti-Racism Task Force Member Networking Outreach and Community Service Training Analyst/Supervising Analyst/PPT Supervisor Circle of Security Parenting

Psychoanalytic Interests

Download Bylaws

Bylaws of the Psychoanalytic Center of the Carolinas

RepresentationDeclare Yes or No to the following questions.

Has your license ever been restricted or revoked? *

Yes No

Has any licensing board or professional ethics body ever revoked, restricted or required you to surrender your license or found you guilty of a violation of ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence in any state/country or is any such action current or pending?

Have you ever been convicted of a crime in any state or country or are any charges current or pending? *

Yes No

Has your insurance ever been affected? *

Yes No

Have you ever had any insurance company decline, cancel, refuse to renew or accept only on special terms any professional liability insurance?

Have you ever had a liability claim filed against you? *

Yes No

Has any professional liability claim or suit ever been made against you or is any such action current or pending?

Are you aware of any circumstances that could cause a claim? *

Yes No

Are there any circumstances of which you are aware that may result in any professional liability claim or suit being made against you?

Have you ever been involved with a patient? *

Yes No

Have you ever been engaged in any sexual conduct with any of your current or former patients or any current or former patient’s spouse or any person with a direct relationship to the patient or former patient (for example a guardian, blood relative of the patient or spouse or any person sharing the patient’s domicile)?

Have you ever had privileges restricted or revoked? *

Yes No

Have you ever had any hospital, agency, health care provider, or professional organization deny, restrict or revoke professional or research privileges or invoke probation for any cause other than incomplete medical charts or is any such action current or pending?

Have you ever been suspended by a government program? *

Yes No

Have you ever been suspended, restricted or put on probation by any governmental health program (i.e. Medicare or Medicaid)?

Are you now or have you ever been treated for alcoholism or other drugs? *

Yes No

Have you ever abused alcohol or drugs? *

Yes No

Has your narcotics license ever been suspended, revoked, voluntarily surrendered or probation invoked or is any such action current or pending? *

Yes No

If yes to any question in the section above, please provide explanation for all affirmative responses.

I acknowledge I have received a copy of the Bylaws of the Psychoanalytic Center of the Carolinas and the American Psychoanalytic Association, knowing membership requires Community members to abide by their terms, especially but without limitation the indemnification provisions contained in Article VI(F) (Ethics Committee) and Exhibit 1 (Ethics and Discipline)

Acknowledge Bylaws *

Yes No