Ohio Psychological Association New Member Application

 

Note: OPA Membership is separate from continuing education tracking services.
Click here to register with OPA-MCE to track your CE hours.

Contact Information
First Name
Middle Initial
Last Name
License Number
Degree(s)


Name of individual or group who referred you

REQUIRED

A value is required.

Have you been a member of OPA in the past?



Professional Field (i.e., clinical, counseling, child, I/O, neuropsychology, developmental, MR/DD, rehabilitation, alcohol/drug)

Email (OPA does not release email addresses)

Website

4-digit PIN (letters and/or numbers) for website access:           

A value is required.
The OPA is authorized to communicate with me via:
Fax:

Email:  
 

 

How Should OPA Contact You?

This address may be released to approved providers of continuing education.

Address
Address 2
City
State
County
Zip
Phone Number
Fax

 

How Should Consumers And Other OPA Members Contact You?

This information is used for consumer inquiries, the online OPA membership directory, and the Find a Psychologist Referral Program.

Use Same as Above
Address
Address 2
City
State
County
Zip
Phone Number
Fax

 

Home Address

This address is used for advocacy purposes only – to determine your legislative districts.  This address will not be released, posted, or sold in any way

Use Same as Above
Address
Address 2
City
State
County
9-Digit Zip
Phone Number
 

 

Member Categories
Please Choose One Appropriate Category

Elite Members
President’s Club* - $750.00
Sustaining Member** - $450.00

Please Choose Your Level

Full Members
Licensed before 9/01/06 - $330.00
Licensed 9/01/06 - 8/31/08 - $225.00
($105.00 discount will be applied at checkout)
Licensed 9/01/08 - 8/31/12 - $150.00
($180.00 discount will be applied at check out)
Licensed 9/1/12 or after - $100.00
($230.00 discount will be applied at checkout)

Affiliate/Student Members
Affiliate members are ineligible to vote or hold office, and have limited participation on OPA listservs.


Affiliate member - non-licensed individuals who may advance the purpose of OPA (endorsement form required) - $50.00

Briefly state your reason for applying for membership in OPA


Psychology Trainee or Student (working toward a psychology degree/license) - $25.00

Discounts are available for full members who are:

  • Not currently practicing or teaching in the state of Ohio
  • Not working/not currently employed in the field of psychology
  • Retired or partially retired
  • Undergoing financial hardship or special circumstances

Contact the OPA Central Office for information about possible discounted membership dues.  Separate application required.

*President's Club members receive a $75.00 OPA continuing education discount coupon, free half-day attendance at the annual OPA convention, free membership to the OPA Find a Psychologist referral program, special notation in quarterly OPA publications/on the OPA website, and are invited to attend the President's Club dinner.

**Sustaining members receive a $50.00 OPA continuing education discount coupon, free membership to the OPA Find a Psychologist referral program, and special notation in quarterly OPA publications and on the OPA website.


 

Affiliation

Check all that apply

   
APA 
APA Divisions?


If so, list current Division(s) of which you are a member

OPA Affiliate Group(s)?  

Akron APP (AAPP)  
Central Ohio PA (COPA)  
Cincinnati APP (CAPP)     
Cleveland PA (CPA)  
Dayton APA (DAPA)    
Toledo AAPP (TAAPP)     
Ohio School Psychologists Association (OSPA)      
Ohio Women in Psychology (OWP)

Other Group(s)?           

Asian American Psychological Association (AAPAsi)  
Association of Black Psychologists (ABPsi)            
National Latino Psychological Association   (NLPA)
Society of Indian Psychologists (SIP)  

 

 

Demographics (optional)

Check all that apply

Gender Female: Male:
Your Ethnicity:

American Indian/Eskimo    
Appalachian  
Asian/Asian-American   
Black/African American  
Hispanic/Latina/Latino   
Pacific Islander  
White/European American   
Bi/Multi-Racial

Other

Psychological Setting:

Academic/Research (including students)
Business  
Hospital            
Military 
Private Practice                    
Public Sector           
Retired  

Other

Average Annual Salary from Psychology:

0 - $19,999                         
$20,000 - $39,999           
$40,000 - $59,999             
$60,000 - $79,999           
$80,000 - $99,999             
$100,000 - $124,999           
$125,000 - $149,999                 
$150,000 and above   
        

Date of Birth

 

Optional OPA Services

Check all that apply

 

Find a Psychologist Referral Program

Consumers can search anonymously at www.ohpsych.org for clinicians in their area.  The OPA central office handles a minimum of 10 telephone referral requests per day and the online referral page receives approximately 475 views per week.  Members can opt-in for a complimentary listing (including name, office phone number and county only) or upgrade to a premium listing (including office address, practice areas/specialties and additional referral demographic information).  President’s Club & Sustaining members join free.  Must be an Ohio licensed psychologist to join.

    

Media Resource Guide:

Are you willing to be contacted by media regarding issues in psychology?   Students are not eligible to participate.  No charge for participation.

Yes, I’ll participate

No thanks

 

Grassroots Advocacy Network:

Help promote psychology’s legislative and regulatory agenda by receiving and responding to timely advocacy alerts.  No charge for participation.

Yes, I’ll participate

No thanks

         

 

 

OPA Email Lists

No charge for participation.

General forum (OPA-LINK) - Affiliate members are not eligible to participate on this list.

Subscribe to OPA’s open forum for members to network and discuss current issues in the field of psychology.

News Flash (OPA-NEWS) – NO CHAT LIST - Open to all member types.

Periodic news/announcements from OPA central office.  Note: OPA-LINK subscribers need not subscribe to this list.

Early Career Psychologist (OPA-EARLY) - Members or non-members licensed within the past seven years.

OPA’s forum for recently licensed individuals to discuss early career issues.

LGBT (OPA-LGBT) - Open to all member types.

Subscribe to discussion on lesbian, gay, bisexual, and transgender issues pertaining to the field of psychology.

Prescriptive Privileges (OPA-RXP) - Open to all member types.

Forum for individuals to discuss issues relevant to advocating for prescriptive privileges for psychologists in Ohio.               

Small College (OPA-SM-COL) - Open to small college faculty.

Forum to encourage dialogue and facilitate collaboration among small college psychology faculty in Ohio

College/University affiliation (required for subscribers of this list)

Student (OPA-STUDENT) - Student members only.

Subscribe to this open forum to network and discuss current student/new psychologist issues in psychology.

 

Contributions

Check all that apply

OPA-PAC (Political Action Committee)

OPA-PAC supports state political activities that impact psychologists and consumers by contributing to campaigns and candidates that can make a difference for our members. As an unincorporated political action committee, contributions are not tax deductible.  No corporate checks or corporate credit cards can be accepted for payment of your OPA-PAC donation.

Personal Visa or MasterCard only - no corporate checks

Contribution amount (suggested $25):  enter Amount $ .00

OPA Project FAIR (Focused Advocacy Insurance Reform)

OPA Project FAIR was founded in 1997 to address the mounting concerns psychologists have with managed care and insurance company problems.  Contributions are tax-deductible.

Contribution amount (suggested $10): 
enter Amount $ .00

 

The Foundation for Psychology in Ohio (PSYOHIO)

The foundation is a non-profit, charitable organization that supports educational programs, scholarships, science day prizes, research, and other programs that benefit the science and practice of psychology.  Contributions are tax deductible.

 

Contribution amount (suggested $15):
enter Amount $ .00

 

 


 

Professional Ethics Declaration & Signature

Please check all that apply

1. Have you ever been denied membership by

a. a professional organization?     No

Please make a selection.
          

b. a state licensing/credentialing board? No
Please make a selection.

 

 

2. Have you ever had any action taken against you as the result of a review or investigation by

a. a professional organization? No
Please make a selection.
                                          

b. a state licensing/credentialing board? No
Please make a selection.

3. Are you presently under investigation by

a. a professional organization? No
Please make a selection.
                                            

b. a state licensing/credentialing board? No
Please make a selection.

4. For reasons concerning/in connection with an ethical or legal issue, have you ever voluntarily or involuntarily relinquished:               

a. professional work responsibilities? No
Please make a selection.
                 

b. membership in a professional organization? No
Please make a selection.

5. Have you ever been indicted for or convicted of a felony?

No
Please make a selection.

6. Have you ever been a party to an out-of-court settlement involving actual or claimed malpractice?

No
Please make a selection.

7. Have you ever had a malpractice judgment entered against you in any court proceeding or arbitration hearing?

No
Please make a selection.

If you answered “yes” to any of the above, please provide the following, either in the text box below or via e-mail to Joan Bowman:  (a) a brief description of the matter, (b) its final result or current status and (c) any key documents regarding the charges, your defense and any ruling.

 

Payment Method

Married couples or life partners of psychologists who are full members of OPA may reduce their combined dues by $25.

Select if applicable. Please list Name of Spouse or Life Partner

 

Membership Dues:                        

Optional Services:                                                                                

Contributions:                           

Service Fee:                                                                     

Total Due Today.             (If you choose payments the amount will reflect the amount of each payment)

 

You must chooses a payment option befor proceeding to checkout







*If paying in installments, your card must not expire before 08/14.

      

Click to proceed to Online Payment Screen

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Your dues include a subscription to The Ohio Psychologist and The Ohio Psychologist Review ($50 value).

Deductibility:  Dues payments, contributions or gifts to the Ohio Psychological Association are not tax deductible as charitable contributions for tax purposes.  They may be deductible as ordinary and necessary business expenses subject to the restrictions imposed as a result of lobbying activities.  OPA estimates that for the association’s fiscal year September 1, 2012 to August 31, 2013, 20% of dues were allocated to lobbying activities and are non-deductible; OPA estimates that for the association’s fiscal year September 1, 2013 to August 31, 2014, 20% of dues will be allocated to lobbying expenditures and are non-deductible.