Register Online Your Info First Name* Last Name* Professional DesignationTraineeRegistered Associate MFTRegistered Associate PCCRegistered Associate CSWRegistered Psychological AssistantMFTLPCCLCSWPh.D.Psy.D.MD Type of Membership:*Licensed Members $ 35.00Students or Trainees or Interns $ 25.00 Organization Agency or Organization (if applicable)License Information License Type License Number Interns (Supervisor Info, if Applicable): Supervisor's Full Name Registration Type | Number Contact InfoEmailYour address will only be used for within group contact and to subscribe you to our listserv. Once you are added to our email list, please send your introduction/bio to the group so that we know about you and your work and we can welcome you: Work Email Address: * This is for internal use only; your email address will not appear on your profile page. Professional Website: Please format website address as: http://www.yourwebsitehere.com. *Site listings are for Psychotherapy Services ONLY! You must either be licensed to provide those services or you should be able to list your supervisor's license under which you practice mental health and counseling services. Work Phone Number:* Required phone number format: (###) ###-####Work/Office Address: Street Address:* Street Address 2: City* State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code* About Yourself How did you hear about us? BrochureClientColleagueEventFriendGaylestaGoogleKink-Related WebsiteOpen Minds MemberOnlineOrganizationSchoolStreet Fair TablingSFSITwitter Would you like your listing made public to visitors of our site?* Yes - please list me on the Open Minds web siteNo - do not list me on the site. Site listings are for Psychotherapy Services ONLY: You must either be licensed to provide those services or you should be able to list your supervisor's license under which you practice mental health and counseling services. Biographical Info Bio PhotoUpload Picture will render square after the upload - do not worry if the picture looks cropped here. Photos uploaded should be SQUARE for best results. Pictures should be uploaded only in the .jpg or .png file type. Recommended image size should be 250px by 250px. If you photo is not uploaded correctly, you may need to reduce the file size of the image to less than 64MB. 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(Or Command + Click) I agree to abide by the ethics code of my profession.*I agree Membership in our organization is not meant to replace professional training in working with alternative sexuality and gender diversity. *I agree Membership Statement of Intent* While you may work with diverse clients, we want to be sure you are also committed to working with kink and poly identified folks. **For internal use only. Will not be published in the directory.** Membership Agreement*I have read understood and accepted the rules for membership as stated above. Username* Password* Minimum length of 7 characters. The password must have a minimum strength of Medium.Strength indicator Repeat Password* Payment Method*PayPalMail a Check (Manual/Offline)Please select an option below to register. If you choose to pay with PayPal your member profile will be activated once it is manually approved by the administrator. You may also register and pay by check (Select Manual/Offline), but your membership will take longer to process. Your membership profile will be saved as a draft until a check is received by Bay Area Open Minds, at which point the website administrator will manually approve your profile and activate your listing.Pay by PayPal or By Credit CardLicensed Members - $35.00 / 1 YearLicensed MembersStudents, Trainees & Interns - $25.00 / 1 YearStudents, Trainees & InternsAutomatically renew subscriptionDiscount Code: Applying discount code. Please wait... 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