American Distance Counseling Association Membership Application

Membership Application

Membership Requirement- One year online counseling experience is required for ADCA Clinical Membership. This can be verified with your counseling site URL and one professional reference who will substantiate your online experience.

Please submit your fee first, by clicking on one of the links:

Clinical Membership $45.00 per year
Academic Membership $55.00 per year (with prior agreement)

SECTION 1 - Contact Information
Name: (First and Last)
Email Address
Re-Type Email Address
Street Address
City
State and Zip Code
Home Telephone
Office Telephone
Date of Birth
Online Counseling Website

Where did you learn about American Distance Counseling Association?
	ConnectForTherapy.com	eTherapyTraining.org
	eTherapyWeb.com	ISMHO.org
	Professional Colleague	Other

SECTION 2 - Education and Licensure
Highest Degree
Major
School
Date Graduated
License #
State of Licensure
Discipline

Reference: List name, telephone number and email address of a reference who can verify your online practice.

Experience: Describe your distance counseling experience. (minimum one year experience for clinical members)

Training: Describe any continuing education credits you have relating to online counseling or delivery of online education.

SECTION 3 - Membership Categories
	Clinical Member $45 / Yearly. Masters degree, State Board License, at least one year of distance counseling		Academic Member $55 / Yearly. Non Clinical - Educational - Technology or Support services of Distance Counseling*

*ADCA Board review and approval required for all Academic Memberships

Submit Application