MEMBERSHIP APPLICATION
FOR
FELLOWSHIP OF CHRISTIAN COUNSELORS –
2009
Membership Application Download Attachment
Here
Please complete the information requested
and return to:
Family Care Center, c/o
7400 E. State
Blvd.,
Fort
Wayne,
IN
46815
Attn: Gret Machlan
PLEASE NOTE THIS CHANGE: The directory information
will be made available to referral sources and on our webpage
at www.fellowshipofchristiancounselors.com.
DUES: $25 (professionals), $10
(full-time students)
Make Checks Payable to: Fellowship of Christian
Counselors
IDENTIFY WHAT YOU WANT LISTED IN OUR
PUBLISHED DIRECTORY:
Name:
_______________________________________________
Credentials: ____________ Students
(specify school, program) ________________
Agency Name:
_________________________________________________________
Agency / Work Address:
_____________________________________ Zip:
_________
Work Phone: ( )
________________
Fax:
( )
________________
Other Phone number(s) for the
directory: ( )
_____________________
E-Mail:
___________________________ Web-page:
__________________________
Days/hours (mark all that apply): Mon-Fri, Saturday, Sunday,
Evenings, Other ________
Populations Served (mark all that
apply): children,
adolescents, adults, couples, families
Additional Therapeutic Specialties:
__________________________________________
Fluent in languages other than English
(specify):
_______________________________
Fees / Third Party Reimbursement (mark
all that applies): Most 3rd party
insurances,
Fee-for-Service, Sliding-scale,
Other:
___________________
Church Affiliation:
__________________________________
FOR OFFICE USE ONLY:
Dues paid: $_______ Date: ________ Directory: _________ Initial: _____
