Ohio Psychological Association New Member Application

Note: OPA Membership is separate from continuing education tracking services.
Click here to register with OPA-MCE to track your CE hours.

Contact Information
First Name
Middle Initial
Last Name
License Number
Degree(s)
Date of Birth
Gender	Female: Male:
OPA member or affiliate group that referred you
Have you been a member of OPA in the past?	Yes No
Professional Field (i.e., clinical, counseling, child, I/O, neuropsychology, developmental, MR/DD, rehabilitation, alcohol/drug)
E-Mail Address (OPA does not release e-mail addresses, but they are included in the membership directory)
Web Site
The OPA is authorized to communicate with me via:
Fax: Yes No
Email: Yes No
4-digit PIN (letters and/or numbers) for website access:

How Should OPA Contact You?
This address may be released to approved providers of continuing education.
Address
Address 2
City
State
County
Zip
Daytime Phone Number
Fax

How Should Consumers And Other OPA Members Contact You?
This information is used for consumer inquiries, the online OPA membership directory, and the Online Psychologist Referral Program.
Use Same as Above
Address
Address 2
City
State
County
Zip
Daytime Phone Number
Fax

Home Address
This address is used for advocacy purposes only – to determine your legislative districts. This address will not be released, posted, or sold in any way
Use Same as Above
Address
Address 2
City
State
County
9-Digit Zip
Phone Number

Member Categories
Please Choose One Appropriate Category
Benefactor Members President’s Club* - $750.00 Sustaining Member** - $450.00
Full Members Member - Licensed 7 Years Or More - $330.00 Early Career - Licensed 5-7 Years As Of September 1- $225.00 Early Career - Licensed 0-5 Years As Of September 1 - $150.00
Affiliate/Student Members Affiliate members are ineligible to vote or hold office, and have limited participation on OPA listservs. Affiliate member - non-licensed individuals who may advance the purpose of OPA (endorsement form required) - $50.00 Student or Psychology Trainee (working toward a psychology degree/license) - $25.00
Discounts are available for individuals who are: Not currently practicing or teaching in the state of Ohio Not working/not currently employed in the field of psychology Retired or partially retired Undergoing financial hardship or special circumstances Contact the OPA Central Office for information about possible discounted membership dues. Separate application required. President's Club members receive a $75.00 OPA continuing education discount coupon, free half-day attendance at the annual OPA convention, free membership to the OPA online referral program, special notation in quarterly OPA publications/on the OPA website, and are invited to attend the President's Club dinner. *Sustaining members receive a $50.00 OPA continuing education discount coupon, free membership to the OPA online referral program, and special notation in quarterly OPA publications and on the OPA website.

Affiliation
Check all that apply

APA
APA Divisions?	If so, list current Division(s) of which you are a member
OPA Affiliate Group(s)?	Akron APP (AAPP) Central Ohio PA (COPA) Cincinnati APP (CAPP) Cleveland PA (CPA) Dayton APA (DAPA) Toledo AAPP (TAAPP) Ohio School Psychologists Association (OSPA) Ohio Women in Psychology (OWP)
Other Group(s)?	Asian American Psychological Association (AAPA) Association of Black Psychologists (ABPSI) National Latino Psychological Association Society of Indian Psychologists (SIP)

Demographics (optional)
Check all that apply

Your Ethnicity:	American Indian/Eskimo Appalachian Asian/Asian-American Black/African American Hispanic/Latina/Latino Pacific Islander White/European American Bi/Multi-Racial Other
Psychological Setting:	Academic/Research Business Hospital Military Private Practice Public Sector Retired Other
Average Annual Salary from Psychology:	0 - $19,999 $20,000 - $39,999 $40,000 - $59,999 $60,000 - $79,999 $80,000 - $99,999 $100,000 - $124,999 $125,000 - $149,999 $150,000 and above

Optional OPA Services

Check all that apply

Online Psychologist Referral Program

Consumers can search anonymously at www.ohpsych.org for clinicians in their area. The OPA central office handles a minimum of 10 telephone referral requests per day and the online referral page receives approximately 475 views per week. Members can opt-in for a complimentary listing (including name, office phone number and county only) or upgrade to a premium listing (including office address, practice areas/specialties and additional referral demographic information). President’s Club & Sustaining members join free. Must be an Ohio licensed psychologist to join.

Opt-In For Complimentary Listing

Premium Listing - Licensed 0-5 Years ($15)

Premium Listing - Licensed 5+ Years ($30)

Media Resource Guide:

Are you willing to be contacted by media regarding issues in psychology? Form will follow to note areas of expertise and best methods of communication. Students are not eligible to participate. No charge for participation.

Yes, I’ll participate

No thanks

Grassroots Advocacy Network:

Help promote psychology’s legislative and regulatory agenda by receiving and responding to timely advocacy alerts. No charge for participation.

Yes, I’ll participate

No thanks

OPA Email Lists

No charge for participation.

General forum (OPA-LINK) - Affiliate members are not eligible to participate on this list.

Subscribe to OPA’s open forum for members to network and discuss current issues in the field of psychology.

News Flash (OPA-NEWS) – NO CHAT LIST - Open to all member types.

Periodic news/announcements from OPA central office. Note: OPA-link subscribers need not subscribe to this list.

Early Career Psychologist (OPA-EARLY) - Members or non-members licensed within the past two years.

OPA’s forum for recently licensed individuals to discuss early career issues.

LGBT (OPA-LGBT) - Open to all member types.

Subscribe to discussion on lesbian, gay, bisexual, and transgender issues pertaining to the field of psychology.

Prescriptive Privileges (OPA-RXP) - Open to all member types.

Forum for individuals to discuss issues relevant to advocating for prescriptive privileges for psychologists in Ohio.

Small College (OPA-SM-COL) - Open to small college faculty.

Forum to encourage dialogue and facilitate collaboration among small college psychology faculty in Ohio

College/University affiliation (required for subscribers of this list)

Student (OPA-STUDENT) - Student members only.

Subscribe to this open forum to network and discuss current student/new psychologist issues in psychology.

Contributions

Check all that apply

OPA-PAC (Political Action Committee)

OPA-PAC supports state political activities that impact psychologists and consumers by contributing to campaigns and candidates that can make a difference for our members. As an unincorporated political action committee, contributions are not tax deductible. No corporate checks or corporate credit cards can be accepted for payment of your OPA-PAC donation.

Personal Visa or MasterCard only - no corporate checks

Contribution amount (suggested $25): enter Amount $ .00

OPA Project Fair (Focused Advocacy Insurance Reform)

OPA Project Fair was founded in 1997 to address the mounting concerns psychologists have with managed care and insurance company problems. Contributions are tax-deductible.

Contribution amount (suggested $10):
enter Amount $ .00

The Foundation for Psychology in Ohio (PSYOHIO)

The foundation is a non-profit, charitable organization that supports educational programs, scholarships, science day prizes, research, and other programs that benefit the science and practice of psychology. Contributions are tax deductible.

Contribution amount (suggested $15):
enter Amount $ .00

Professional Ethics Declaration & Signature

Please check all that apply

1. Have you ever been denied membership by

a. a professional organization? yes no

Please make a selection.

b. a state licensing/credentialing board? Yes No
Please make a selection.

2. Have you ever had any action taken against you as the result of a review or investigation by

a. a professional organization? Yes No
Please make a selection.

b. a state licensing/credentialing board? Yes No
Please make a selection.

3. Are you presently under investigation by

a. a professional organization? Yes No
Please make a selection.

b. a state licensing/credentialing board? Yes No
Please make a selection.

4. For reasons concerning/in connection with an ethical or legal issue, have you ever voluntarily or involuntarily relinquished:

a. professional work responsibilities? Yes No
Please make a selection.

b. membership in a professional organization? Yes No
Please make a selection.

5. Have you ever been indicted for or convicted of a felony?

Yes No
Please make a selection.

6. Have you ever been a party to an out-of-court settlement involving actual or claimed malpractice?

Yes No
Please make a selection.

7. Have you ever had a malpractice judgment entered against you in any court proceeding or arbitration hearing?

Yes No
Please make a selection.

If you answered “yes” to any of the above, please provide the following, either in the text box below or via e-mail to Denise Brenner: (a) a brief description of the matter, (b) its final result or current status and (c) any key documents regarding the charges, your defense and any ruling.

Payment Method
Married couples or life partners of psychologists who are full members of OPA may reduce their combined dues by $25. Check if Applicable. Please list Name of Spouse or Life Partner
Membership Dues: Optional Services: Contributions: Service Fee: Total Due Today. (If you choose payments the amount will reflect the amount of each payment) *If paying in installments, your card must not expire before 08/12.
Click to proceed to Online Payment Screen	Payment Button Will Not work if there are errors on the form. Please Check for errors in Red
Your dues include a subscription to The Ohio Psychologist and The Ohio Psychologist Review ($50 value). Deductibility: Dues payments, contributions or gifts to the Ohio Psychological Association are not tax deductible as charitable contributions for tax purposes. They may be deductible as ordinary and necessary business expenses subject to the restrictions imposed as a result of lobbying activities. OPA estimates that for the association’s fiscal year September 1, 2011 to August 31, 2012, 20% of dues were allocated to lobbying activities and are non-deductible; OPA estimates that for the association’s fiscal year September 1, 2012 to August 31, 2013, 20% of dues will be allocated to lobbying expenditures and are non-deductible.

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