AAMHA Membership Application 2023
Thank you for your interest in becoming a member of the Armenian American Mental Health Association.

Address : P.O.Box 588, Glendale, California 91209
Email: aamhawest@gmail.com
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First and Last Name
Date of Birth (MM/DD)
Mailing Address
Telephone Number
Email Address to receive AAMHA emails
Name of School
Degree
Occupation
License Type & # (If associate: supervisor name, license type & #)
Work Name/Type (i.e. private practice, agency, school)
Work Address
Work Phone
Work Email
Website
Name 1 population and 1 issue you work with
Languages Spoken (If Armenian, indicate eastern and/or western dialects)
Fee for services (If you want it included in the Directory)
Sliding Scale Offered?
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Insurance Taken? If yes, which ones?
Would you like your work information above to be listed in our member directory?
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If yes, what are you available for?
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Would you like to join a committee?
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Do you hold an active license?
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Have you been denied/revoked membership to other organizations?
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Member Type
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If you are applying for affiliate membership and do not currently hold a Masters degree in a mental health field, please explain why you would like to join AAMHA and how your professional/personal history demonstrates a strong interest or involvement in the mental health field

Annual membership/donation of $40 payable via Zelle at aamhawest@gmail.com  or personal check made out to AAMHA and mailed to AAMHA PO Box.
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Your signature below acknowledges you agree to AAMHA's bylaws, statements, membership dues. You further acknowledge that all information you provided is true and accurate:
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