Member
2009 MEMBERSHIP APPLICATION FOR FELLOWSHIP OF CHRISTIAN COUNSELORS
Membership dues can be paid by using our online PayPal interface (you do not need a PayPal account to use this) or by sending check or money order to:
LifeWorks Counseling and Consulting, Inc. 6202 Constitution Dr. Suite D, Fort Wayne, IN 46804
Attn: Gret Machlan
For online renewal choose the appropriate membership level via the PayPal button –Visa and Master Charge will be accepted. Put your name in the checkout box which says “Add special instructions to seller.” After payment is made, copy and paste the form below to your email client, fill it out and send to president@fellowshipofchristiancounselors.com
Membership Application Download Attachment Here
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2009 FCC Membership Application
DUES: $25 (professionals), $10 (full-time students)
Make Checks Payable to: Fellowship of Christian Counselors
PLEASE IDENTIFY WHAT INFORMATION (PERSONAL OR PROFESSIONAL) YOU WOULD LIKE LISTED IN OUR ONLINE DIRECTORY– (MAKE AN “x” IN EACH OF THE FIELDS THAT YOU WOULD LIKE PUBLISHED OR PROMOTED ONLINE. THIS INCLUDES PERSONAL/PROFESSIONAL WEBSITES WHICH WILL RECEIVE A HOTLINK FROM THE FCC SITE).
Name: _______________________________________________
Credentials: ____________ Students (specify school, program) ________________
Agency Name: _________________________________________________________
Agency / Work Address: _____________________________________ Zip: _________
Work Phone: ( ) ________________ Fax: ( ) ________________
Other Phone number(s) for the directory: ( ) _____________________
E-Mail: ___________________________ Web-page: __________________________
Days/hours (mark all that apply): Mon-Fri, Saturday, Sunday, Evenings, Other ________
Populations Served (mark all that apply): children, adolescents, adults, couples, families
Additional Therapeutic Specialties: __________________________________________
Fluent in languages other than English (specify): _______________________________
Fees / Third Party Reimbursement (mark all that applies): Most 3rd party insurances,
Fee-for-Service, Sliding-scale, Other: ___________________
Church Affiliation: __________________________________
I want to be listed in the online directory: yes_____no_____
FOR OFFICE USE ONLY:
Dues paid: $_______ Date: ________ Directory: _________ Initial: _____
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