MEMBERSHIP APPLICATION FOR

FELLOWSHIP OF CHRISTIAN COUNSELORS – 2008

Please complete the information requested and return to: 

Fellowship of Christian Counselors

 c/o Gret Machlan, 2121 St. Joseph Blvd., Fort Wayne, IN  46805

The directory information will be made available to all members of FCC.  Downloadable membership application here.  

For more information please review our membership details here.

DUES:  $25 (professionals),  $10 (full-time students)

Make Checks Payable to:  Fellowship of Christian Counselors

FOR RETURNING MEMBERS:  Please complete name, address, phone, e-mail address; plus any additional information that has changed.

Name:  _______________________________________________________________

Credentials:  ____________     Students (specify school, program) _________________

Agency/Counseling Practice:  ______________________________________________

Address:  ______________________________________________________________

Mailing Address:  (if different from above):  __________________________________

Phone:  Home:  (      ) ________________      Office:    (      ) ________________     

             Cell:     (      ) ________________      Fax:        (      ) ________________      

      TDD/TTY:  (      ) ________________     

E-Mail:  ___________________________   Web-page:  __________________________

Days/hours (open for business):

Therapeutic Services / Specialties: 

Fluent in languages other than English?

Other professional organization memberships?

Fees / Third Party Reimbursement: 

Church Affiliation: 

FOR OFFICE USE ONLY: 

Dues paid:  $_______  Date: ________   Directory:  _________   Initial: