Please provide as much data as possible to help us maintain our LA4PT database.
* indicates required
Mr., Ms, Mrs., Dr., Capt., etc.
PhD, MS, BA, etc.
RPT or RPT-S Credentials, or None
Supervisor, Therapist, Counselor, etc.
ID if known
(Professional, Affiliate or Friend)
(Expiration date for Membership, IF KNOWN - mm/dd/yy)
mm/dd/yy OPTIONAL
( ) -
Please use (xxx) xxx-xxxx format
( ) -
Please use (xxx) xxx-xxxx format
(Where you work.)
Address Line 1
Address Line 2 ( if needed)
Your ZIP code
USA or other
mm/dd/yy
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