Name:

Office Addresses (street, unit, city, zip):

Preferred Mailing Address:

Office Phone(s):

(Optional)Home Phone:                                    Fax:                                            Additional Phone(s):

E-mail:

Institution and Field of Study:                                                                     Degree:

Additional Credentials, Training, Affiliations:

Please describe your therapeutic orientation and the nature of your therapy practice, Including descriptions of your areas of specialty, the types of referrals you want, and referrals you do not want):

Number of cases you have worked with a surrogate partner? (circle) 0       1-5       5-10        11-19       20+

Sponsoring Member(s):

1.

2.

Mail application and $25.00 check for your first year dues to:IPSA
3428 Motor Avenue,
Los Angeles, CA 90034

For information or assistance, contact the Membership Committee.