Login Details
E-Mail*:
[jp_join_field fieldtype=”text” name=”email” required=”true”]
Membership Details
Password*:
[jp_join_field fieldtype=”pass” name=”pass” required=”true”]
Repeat Password*:
[jp_join_field fieldtype=”pass” name=”passrepeat” required=”true”]
Membership Category*
[jp_join_radioMCAT defaultmembertype=”IndividA12Month” display=”table” ]
Personal Information
Prefix
[jp_join_dropdowns name=”prefix” dd_override=”prefix”]
First Name*
[jp_join_field fieldtype=”text” name=”fname” required=”true”]
Preferred Name
[jp_join_field fieldtype=”text” name=”pref_name”]
Middle Name
[jp_join_field fieldtype=”text” name=”mname”]
Last Name*
[jp_join_field fieldtype=”text” name=”lname” required=”true”]
Display Name*
[jp_join_field fieldtype=”text” name=”disp_name” required=”true”]
Suffix
[jp_join_dropdowns name=”suffix” dd_override=”suffix”]
Title*
[jp_join_field fieldtype=”text” name=”jtitle” required=”true”]
Date of Birth*
[jp_join_field name=”dob” fieldtype=”datepicker” required=”true”]
Degrees*
[jp_join_dropdowns name=”desig” dd_override=”desig” multiple=”true” required=”true”]
Other Degree(s)
[jp_join_field fieldtype=”text” name=”desig_other”]
Gender
[jp_join_dropdowns name=”gender” dd_override=”gender”]
Race
[jp_join_dropdowns name=”ethnicity” dd_override=”ethnicity”]
Contact Information
Primary Address
Address Type
Country*
[jp_join_dropdowns name=”addresses,0,country” dd_override=”country” required=”true” onchange=”JPDropDown.countryChangeHandler($(‘#JoinForm’))”]
Street Address Line 1*
[jp_join_field fieldtype=”text” name=”addresses,0,add1″ required=”true”]
Street Address Line 2
[jp_join_field fieldtype=”text” name=”addresses,0,add2″]
City*
[jp_join_field fieldtype=”text” name=”addresses,0,city” required=”true”]
[jp_join_dropdowns name=”addresses,0,us_state” style=”display:block;” dd_override=”state” required=”true”][jp_join_field fieldtype=”text” name=”addresses,0,state” style=”display:none;”]
Zip*
[jp_join_field fieldtype=”text” name=”addresses,0,zip” required=”true” required=”true”]
Phone*
[jp_join_field fieldtype=”text” name=”addresses,0,phone” required=”true”]
Company*
[jp_join_field fieldtype=”text” name=”addresses,0,company” required=”true”]
If retired type RETIRED
Secondary Address
Address Type
Street Address Line 1
[jp_join_field fieldtype=”text” name=”addresses,1,add1″]
Street Address Line 2
[jp_join_field fieldtype=”text” name=”addresses,1,add2″]
City
[jp_join_field fieldtype=”text” name=”addresses,1,city”]
State
[jp_join_dropdowns name=”addresses,1,us_state” style=”display:block;” dd_override=”state”] [jp_join_field fieldtype=”text” name=”addresses,1,state” style=”display:none;”]
Zip
[jp_join_field fieldtype=”text” name=”addresses,1,zip”]
Country
[jp_join_dropdowns name=”addresses,1,country” dd_override=”country” onchange=”JPDropDown.countryChangeHandler($(‘#JoinForm’))”]
Phone
[jp_join_field fieldtype=”text” name=”addresses,1,phone”]
Company
[jp_join_field fieldtype=”text” name=”addresses,1,company” ]
If retired type RETIRED
Professional Details
[jp_join_dropdowns name=”medical_school” dd_override=”medical_school” required=”true”]
When did/will you complete medical school?
[jp_join_field name=”medical_sch_cmp_date” fieldtype=”datepicker”]
Medical, NP, or PA school name (or list “N/A”)
[jp_join_field fieldtype=”text” name=”medical_school_name” ]
[jp_join_dropdowns name=”residency_complete” dd_override=”residency_complete” required=”true”]
When did/will you complete your residency?
[jp_join_field name=”residency_cmp_date” fieldtype=”datepicker”]
[jp_join_field fieldtype=”text” name=”residency_program_name” ]
[jp_join_dropdowns name=”fellow_complete” dd_override=”fellow_complete” required=”true”]
When did/will you complete your fellowship?
[jp_join_field name=”fellowship_cmp_date” fieldtype=”datepicker”]
[jp_join_field fieldtype=”text” name=”fellowship_name” ]
[jp_join_dropdowns name=”profession” dd_override=”profession” multiple=”true” required=”true”]
[jp_join_field fieldtype=”text” name=”profession_other” ]
If MD/DO: list specialties or sub-specialties.
[jp_join_dropdowns name=”interest” dd_override=”interest” multiple=”true”]
[jp_join_field fieldtype=”text” name=”expertise” required=”true”]
[jp_join_field fieldtype=”text” name=”interest_other” ]
[jp_join_field fieldtype=”textarea” name=”honors”]
Are you ABPN Board Certified?*
[jp_join_field fieldtype=”boolean” name=”abpn_certified” ]
[jp_join_field fieldtype=”boolean” name=”ama_member” ]
[jp_join_field fieldtype=”boolean” name=”apa_member” ]
[jp_join_field fieldtype=”boolean” name=”buprenorphine_waiver” ]
[jp_join_dropdowns name=”primary_practice” dd_override=”primary_practice” multiple=”true” required=”true”]
If other, please specify (or list “N/A”)
[jp_join_field fieldtype=”text” name=”primary_practice_other” ]
[jp_join_dropdowns name=”primary_role” dd_override=”primary_role” multiple=”true” required=”true”]
[jp_join_field fieldtype=”text” name=”primary_role_other” ]
[jp_join_committee]
[jp_join_dropdowns name=”ref_by” dd_override=”ref_by” multiple=”true” required=”true”]
[jp_join_field fieldtype=”text” name=”ref_by_other” ]
When you participate in the AAAP Patient Referral Program, patients who are seeking treatment in your area will be able to find your contact information easily.
[jp_join_field fieldtype=”boolean” name=”patient_referral” ]
[jp_join_field fieldtype=”boolean” name=”search_dir” ]
By submitting this form, I agree to abide by the Charter and Bylaws of the American Academy of Addiction Psychiatry. I understand that the organization will review my application and my references. I will hold the Academy, its’ members, examiners, officers, employees and agents free from all damage and complaint by reason of any action taken on this application or by reason of any subsequent action on membership. I pledge myself to high standards of ethical practice. Being a member of the Academy DOES NOT, at any time or by any means, make me a representative of the organization nor give me the right to speak on its’ behalf.
PLEASE NOTE: All membership applications will be screened. AAAP does not endorse or support the membership of each member or respective organization. Upon becoming a member, you are not a representative of the organization. Members will not speak on behalf of the organization unless asked by the CEO or the Board of Directors. Membership information pertaining to fellow Academy members is not for solicitation, distribution or unauthorized use. Members using the membership directory or member information inappropriately could face termination. The Academy will review applications and references as it sees fit. Members will hold the Academy, its members, examiners, officers, employees and agents free from all damage and complaint by reason of any action taken on an application or by reason of any subsequent action on membership.
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