Name *

First Name

Last Name

Cell Phone Number *

(to be added to the appropriate Whatsapp group)

(###)

###

####

Mailing Address *

For us to mail your welcome packet!

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Indicate the purpose of completing this form: *

Add yourself as a new MAPS member clinician on our website directory

Update your current listing

Gender *

Male

Female

Other

What age groups do you work with? *

Children (0-11)

Pre-teen (11-13)

Teens (13-18)

Adults

Couples

Pre-parental

Geriatrics

What is your office phone number? *

(###)

###

####

We require all MAPS Clinicians' licensure to be in current and in good standing. Have you ever been subject to a State Board audit or investigation? *

Yes

No

By checking this box, I agree to the MAPS Membership Terms & Conditions *

Copy and paste the link below into your browser to read the MAPS Membership Terms & Conditions. https://www.mapsnetwork.org/terms-and-conditions

I agree

Please select your membership level: *

Intern/Associate - $60/yearly

Professional (Licensed) - $100/yearly

By checking this box, I confirm that I have paid my membership dues via Zelle to maps.dfw@gmail.com. *

I have paid my annual membership dues.

By checking this box, I confirm that I have sent my headshot to maps.dfw@gmail.com *

I have sent my headshot.

By checking this box, I confirm I am a Muslim therapist in the state I selected, and in good standing. *

I confirm I am a Muslim therapist in the state I selected above, and in good licensure standing.