Member Profile

Personal Contact Information

First Name:

Last Name:

Preferred Pronouns:

Profile Description: - (with your permission) this description will appear to the public when they search for a psychologist and then click on your name

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Home Address:

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Work Address:

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Work Address 2:

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Preferred Address:

Preferred Language of Correspondence:

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Country of Birth:

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Contact Phone #:

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Preferred Email:

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User Name:

Password:

Current Employment Data

Currently Employed:

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Region (To select more that one option hold "Ctrl" or "Command"):

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Clientele Demographic (To select more that one option hold "Ctrl" or "Command"):

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Languages in Which Services are provided (To select more that one option hold "Ctrl" or "Command"):

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Therapy and Treatment Approach (To select more that one option hold "Ctrl" or "Command"):

Assessment Services (To select more that one option hold "Ctrl" or "Command"):

Areas of Practice (To select more that one option hold "Ctrl" or "Command"):

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New Clients - Therapy :

New Clients - Evaluation/Assessment:

Offers Telepsychology?:

Regulatory Status

CPNB Licence #:

CPNB Member Status:

Date of Initial License:

Degrees Awarded

Psychology Degree on which license is granted

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Degree Granting Educational Institution:

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Professional Standing

History of Reportable Discipline:

History of any Indictable Offense?:

Professional Liability Insurance Held?:

Professional Will in Place?:

In the event of my disability or death, my client records will be in the custody of the following person at the telephone number provided.
Name:

Contact Number/Email:

Year of Expected Retirement::

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Personal Contact Information

Current Employment Data

Regulatory Status

Degrees Awarded

Professional Standing

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