PSPPR - The Psychological Society of the Pikes Peak Region

Step 1: Registration for membership

Please enter your personal information below.
After clicking on the Submit button you will be taken to step 2,
our secure payment system to complete your registration.

PSPPR Membership information:

Registration type:

Initial Renewal

First Name:

Last Name:

Email:

Address:

City:

State:

Zip:

Work Phone:

Ext:

Home Phone:

Psychologist Member:

Degree:

PhD EdD PsyD Other

Degree Granting Institution:

Licensed in Colorado as a psychologist?

Yes No

Psychology Graduate Student Member:

Degree:

MA MS Other

Degree Granting Institution:

Have you ever been convicted of a felony?

Yes No

Is there a grievance pending against you?

Yes No

Have you ever been found in violation of the APA's Ethical Principals of Psychologists and Code of Conduct?

Yes No

Interested Affiliate
(for non-Psychologists/students who have an interest in Psychology)

Profession:

Web site specific information:

Would you like to be included in the web site members list?

Yes No

If you would like to be included in the psppr.com members directory, please fill in the next section. If not, simply scroll to the bottom of the page and hit "Submit" to be taken to step 2, our secure payment page.

Business Name:

Type of Business:

Private Practice

Academic/Research

Graduate Student

Other

Location of Business:

NW Colorado Springs

NE Colorado Springs

SW Colorado Springs

SE Colorado Springs

Downtown Colorado Springs

Monument/Black Forest Area

Other

Business Address:
( Same as Above)

Business City

Business State:

Business Zip:

Business Phone:

Ext:

Would you like your Business Address published on the PSPPR site?

Yes No

Would you like your Business phone number published on the PSPPR site?

Yes No

Would you like a link to your own web site from the PSPPR site:

Yes No

If yes, please enter your web site address:

Population:
(check all that apply)

Children	Adolescents
Adult	Couples
Families	Geriatric

Description of Services Available/Specialty/Expertise/Accepted Insurance-Provider Panels:

Education Background

Publications/Lectures/Research:
(Please list any work you have had published (books, articles, contributions to psychological journals, etc.)

Comments/Special Needs/Additional Information

By submitting this form I certify that the above statements are true and accurate to the best of my knowledge and understand that any attempt to misrepresent or falsify information presented in this application constitutes grounds for termination of membership. Further, I understand that such misrepresentation will be reported to the state Licensing Board and/or Grievance Board as appropriate. I agree to adhere to the Ethical Principals of Psychologists and Code of Conduct of the American Psychological Association.