SIMHA New Member Application
CONFIDENTIAL INFORMATION
Please print out this form and deliver it to the address at the end of this application or email it to the membership chair (details below).
Note: Information submitted on this form will be retained by SIMHA for two purposes: (1) membership verification and certification, and (2) communication within SIMHA regarding SIMHA affairs. It will not be put to any other use or released to any other party.
Name: _____________________________________________________________________________
Telephone: Office –
________________________________________________________________
Mobile- ________________________________________________________________
Email: _____________________________________________________________________________
Membership Category: Clinical ( ) Associate ( ) Student ( )
Current Title: __________________________________________
Highest Degree: MS/MA ( ) PhD ( ) PsyD ( ) EdD ( ) MSW ( ) BA/BA ( ) MD ( ) Other: _________________
Profession (Check one that best describes):
Psychiatrist ( ) Psychologist ( ) Counseling Psychologist ( ) Clinical Psychologist ( ) Social Worker ( ) School Counselor ( ) School Psychologist ( ) Family Therapist ( ) Psychotherapist ( )
The SIMHA board is comprised of volunteers to ensure the integrity of the organization. Given the voluntary nature required to keep SIMHA operating, we request that every member join at least one committee. You will be contacted by the head of the committee for further instructions. Choose one:
[ ] Website
[ ] Marketing
[ ] Membership and Directory
[ ] Treasurer
[ ] Events
[ ] Crisis Response
What areas are you able to provide continuing education or training in?
Do you have any record of legal convictions? [ ] Yes [ ] No
Have you lost your professional license or had any other disciplinary action including any pending professional reviews or actions to limit your practice?
[ ] Yes [ ] No
If yes to either of these two previous questions, please attach an explanation to this application.
Clinical Members must have:
1) A Master's Degree or higher, or equivalent professional training, in a field of clinical mental health from an institution which is recognized by a regional or national accreditation body. Such training should include both theoretical courses in the specific mental health field and supervised clinical work experience.
2) Have completed at least two years of full-time well-supervised post-master’s clinical experience in their field (or equivalent) defined as: 2,500 contact hours of clinical experience including at least 250 hours of direct supervision with appropriate discipline.
3) Clinical Members must reside in Shanghai as evidenced by 1) possession of non-tourist visa, and 2) presence in, and availability to serve, the Shanghai International community a minimum of eight (8) months per year.
- *Please outline the criteria for and method of becoming eligible for registration or obtaining a license in your mental health profession/s in your home country.
- *Please include website addresses of your licensing board for reference.
- *Please outline how specifically your qualification meets the academic requirements for Clinical Membership.
- *Please outline how specifically you meet the supervision requirements for Clinical Membership.
Associate Members must have:
1) Master's Degree or higher, or equivalent professional training, in a field of clinical mental health from an institution which is recognized by a regional or national accreditation body but not eligible for Clinical Membership due to insufficient contact/supervision hours. Such training should include both theoretical courses in the specific mental health field and supervised clinical work experience.
OR
2) (i) Bachelor's degree in a field of clinical practice, if permitted to practice with a Bachelor's degree in country or state of training,
(ii) Licensed for clinical practice in the country or state of training for their field of practice at the Bachelor's level if such licensure is available,
(iii) Able to document ten (10) years' supervised full-time post-baccalaureate clinical practice.
3) Associate Members must reside in Shanghai as evidenced by 1) possession of non-tourist visa, and 2) presence in, and availability to serve, the Shanghai International community a minimum of eight (8) months per year.
- *Please outline the criteria for and method of becoming eligible for registration or obtaining a license in your mental health profession/s in your home country.
- *Please include website addresses of your licensing board for reference.
- *Please outline how specifically you are eligible for Associate Membership.
- *Please outline specifically what type of supervision you are currently receiving.
Student Members are:
1) Graduate and undergraduate students in mental health fields of clinical practice.
- Please outline how specifically you are eligible for Student Membership
Please read the Code of Ethics available on the Shanghai International Mental Health Association website: www.s-imha.org and print out this form and sign below to indicate your agreement to abide by the SIMHA Code of Ethics
Signature: __________________________________________________________________________
Do you want your profile published: ( ) print directory ( ) web directory
Date: ______________________________________________________________________________
SIMHA Membership Chair
christineforte7@gmail.com
*Be sure to include: 1) this application signed; 2) copy of highest degree; 3) copy of license from home country; 3) copy of current non-tourist visa.
Membership fee (payable upon acceptance): Clinical 800 RMB Associate 600 RMB Student 300 RMB
Membership dues are non-refundable.