ASAP Membership Application - 2025 Version -ASAP

ASAP Membership Application - 2025 Version

Individual Application Form

This is an INDIVIDUAL membership application form.

If you are joining as part of a special "Organizational Affiliate Membership" arrangement, please STOP HERE and do not complete this application (your facility administrator will submit your name along with the organizational membership application, so an individual application is not required).

For any individual member applicants:

Please complete all relevant sections and click "submit".

Questions with asterisks (*) are required.

Once submitted, our Executive Office will forward your application to the Membership committee for review.

ASAP may check references and may make inquiries about any applicant’s training and professional qualifications, if deemed necessary.

PLEASE NOTE!!! - You must complete all "required" sections (marked with an asterisk) or rejection will occur. If, after two attempts you are unable to submit the application, please try the alternative application.

What is your Preferred (non-institutional if possible) Email Address (institutional ones more likely to have firewalls, etc)

What is your First Name?

If you answered "other" above, or if you are able to share the name of who referred you so we can thank them, please write response below. Note: ASAP members who refer applicants receive ASAP loyalty points but only if you identify them!

What is your Last Name?

What is your terminal degree credential abbreviation (M.D., D.O., Ph.D., Masters Degree, ARNP, etc)? If a Medical or Graduate Student, please note.

What is your Birth Date?

What is your PREFERRED Phone Number? Enter your country code (if non-USA), area code, and preferred phone number

What are the Last 4 Digits of Social Security Number? (If non USA Citizen, enter 0000)

What is your mailing address (Street or PO Box, City, State, Zip or Mail Code, and Country (if not US)?

Section 2, PHYSICIANS (and Medical Students) ONLY - If you are not a physician/medical student, skip this section!

If you are NOT a -physician/medical student, please SKIP to SECTION 4.

Where (name of school and location) did you (or will you, if a student) complete your basic Medical Education?

When did you (or will you, if a student) complete your basic medical education?

Where did you complete your residency (facility and location)? If Student, leave blank

If not in general psychiatry, please specify below (skip otherwise):

Date of completion of residency training (if still in training or a student, please put your anticipated graduation)

Additional Post Graduate Training & Degrees (specify type, location, with dates) - skip if not applicable

Additional Board Certification Information

Current Active Medical License (state, number, exp. date) - if not required to have a license, please state reason below.

Are you an active APA/CPA (Canadian Psychiatric Association) Member? Check applicable boxes (as an APA affiliated society, APA/CPA membership is typically required)

yes

no - if no, you must complete one of the boxes below in addition to this one

I meet eligibility criteria for APA/CPA but for personal reasons have chosen not to join or remain

I do not meet eligibility criteria for APA/CPA and have left a detailed explanation below

I am not sure. Please review criteria: https://psychiatry.org/membership/join-apa/general-members

I am not a psychiatrist, but am an active member of my discipline's national society

other - see next section

Please list other professional organizations in which you are actively involved:

Please upload any supporting documents relating to the questions above (not a requirement, but helpful. Documents may be requested later by Membership Committee)

SECTION 3 - RESIDENTS, MEDICAL STUDENTS, AND FELLOWS ONLY: Please complete this section

All other applicants, please SKIP this section and proceed to SECTION 4 or SECTION 5 as appropriate. NOTE: We must verify your status with your training director or (if medical student) your office of academic affairs/admissions. Your application cannot be processed if you do not provide this information and contact information. Thank you.

Please indicate the name and location of the institution where you are presently in training:

Please indicate the date you expect to complete your training program

Please indicate the name of your training director - if Medical Student, the contact at your Office of Academic Affairs

Please give us your training director's email contact information (for purposes of verifying Training status only)

Please provide your training director with this link to complete a brief online form attesting to your current training status and graduation date: https://forms.gle/AufFFUD251LdoNCE9

Yes, I will share this link with my training director

No, I will ask my training director to send an email directly to: asapadolpsych@gmail.com

Your application WILL NOT be processed unless you subscribe here (copy and paste this URL): https://www.adolescentpsychiatry.org/plans-pricing/payment/eyJpbnRlZ3JhdGlvbkRhdGEiOnt9LCJwbGFuSWQiOiJkNmZlYzY2YS1lOWU3LTQ5MzItYmM5NS1mNjQwNzQzZTMzN2QifQ

SECTION 4 - NON-PHYSICIANS ONLY: Complete this section

All other applicants, please SKIP this section and go to SECTION 5

Graduate School (with dates and degree awarded)

Post Graduate Training & Degrees/Certifications (with dates) - skip if not applicable

Internship (if any, with dates) - skip if not applicable

Non-Physician currently-active Certifications/Licenses and States:

Additional Training, Degrees, and Dates:

I am a member of my discipline’s National Society/Association:

Yes

I am eligible for membership but for personal reasons choose not to join or remain a member

I am not eligible for membership

Professional Society/Association Membership(s):

Other Professional Societies (skip if none):

Please upload any supporting documents relating to the Physician or Non-Physician sections above (not required, but helpful; may be requested later by Membership Committee)

SECTION 5: Professional References (If you are applying for Member-In-Training Status, please SKIP this section)

Please complete this section in its entirety - The membership committee reserves the right to ask you to produce written reference letters if requested. If you are applying for membership-in-training status, please skip this section. References are NOT REQUIRED, but they are RECOMMENDED to expedite your application process.

References will expedite your membership application if provided at the time of application and are easiest submitted online using this link, designed specifically for your references to complete easily.

If you prefer, you may copy and paste this URL into your reference request letter: https://forms.gle/GFqxecfbAF6Q4geXA

Otherwise, written letters may be submitted via email to: asapadolpsych@gmail.com

WITHIN THE PAST 12 MONTHS, have you been certified by the American Board of Adolescent Psychiatry (ABAP) or do you have an ABAP application in progress? If yes, we wil use those references and you may skip to Section 6

Yes

If you were you referred by or know an ASAP Member. please list their name. We will contact them on your behalf and you do not need to send any other references unless we contact you for them and therefore should skip the remainder of this section.

Optional - List Reference #1 (name, address, city, state, zip code, email address, and phone numbers) - you may be asked to supply this informaiton later however if not provided now.

Optional - List Reference #2 (name, address, city, state, zip code, email address, and phone numbers) - you may be asked to supply this informaiton later however if not provided now.

If you have letters of reference already available or wish to obtain them to submit with this application, please upload them here (letters are not required but recommended in order to facilitate membership committee approval)

SECTION 6 - Questions and Attestations

All applicants must complete this section.

Have you ever been found at fault by any licensing board or professional ethics committee, or are you now under investigation by any such group?

Yes (please summarize the issue, outcome, and consequences in the section below)

If you answered "yes" above, please explain the action and outcomes/decisions.

Please upload any supporting documentation pertaining to the above question here (optional, skip if not applicable)

I confirm that the information provided on this application is true. I authorize ASAP to contact the above-named references, academic institutions, and organizations if necessary to verify or obtain information regarding my application for membership and/or confirmation of my education, credentials, and/or membership, and hereby release the above named to provide information for this purpose.

Your Signature

Today's Date

SECTION 7 - Membership Category

Please complete this section in its entirety.

ASAP offers several membership categories. Please read about them on our website and then make your request below.

If you are a member of an organization or institution, you should consider the option of organizational membership which allows all clinical staff of your organization to automatically become ASAP members at no charge to them but rather via a negotiated fee paid by their organization on behalf of all of its members.

ASAP Membership is presently offered at no charge to members in training for the duration of their training. For all others, ASAP presently offers a 50% dues discount at the time of payment.

ASAP membership dues are assessed during November and December each year. For members in their first year, membership is prorated or a coupon offering a discount for the next year may be issued (based on when during the year a member joins ASAP) to account for the shortened dues year. (Members-in-training pay no dues, so they are exempt from the annual dues assessment for the duration of their training)

Choose your membership classification below:

Regular Membership (Psychiatrist) - $285/year

Member-in-Training (Residents, Med/Grad Students, Fellows) - FREE MEMBERSHIP for ENTIRE TRAINING

Early Career Psychiatrist (First 5 years post completing of Residency/Fellowship) $214/yr

Associate Membership (Non psychiatrist physicians, non-physicians with graduate degrees) $214/yr

Organizational Membership (see below)

If you selected "organizational membership" above, please list the name and contact information for your facility administrator so we may contact him/her to begin the process involved.

SECTION 8 - ASAP Mentoring Program & Other Opportunities for New Members

The American Society for Adolescent Psychiatry offers Mentoring to new members although it is not required. Mentees are paired with an ASAP Former President, current officer, and/or a member with many years of experience in ASAP as schedules permit. Mentors help new members "find their way" in ASAP and to build their credentials and experience through maximal pairing of their interests with opportunities in and outside of ASAP in the field of Adolescent and Young Adult Psychiatry. We leave it entirely up to the mentor and mentee to determine their focus and frequency of any meetings as well as the duration of their relationship. Members-in-Training are offered a specialized hybrid mentoring experience that combines individual and group activities. THERE IS NO CHARGE FOR MENTORING!

If you are interested in mentoring, please complete this online form at this time.

(If you encounter problems or repeated error messages with the above form, but only if so, please use this alternative online form)

Special Interest Groups and Opportunities

We have created special interest groups for current and new members. It is a way to get to know colleagues and also come together over a common set of interests and passions. We also have several organizational committees to assist us with daily operations or issues in ASAP.

Do you have an interest in assisting ASAP by serving on one of our working committees? If so, please check any that apply and we will contact you once your application is approved.

Administration/Finance/Operations Committee

Membership Committee

Marketing and Media Oversight Committee

Annual Program Committee

Strategic Planning/Bylaws Committee

Ethics Committee

Other (please add at the end of this section)

Please let us know any other interest areas or committees you may be interested in, Blog or Forum Post interests, etc!

Board Certification in Adolescent and Young Adult Psychiatry Opportunity!

Did you know that ASAP offers Board Certification in Adolescent and Young Adult Psychiatry through our hosted American Board of Adolescent Psychiatry (ABAP)? This specialty certification does not require a fellowship, and is most appropriate for General Psychiatrists working with teens and young adults in a variety of settings (traditional, residential, correctional, college, military). Learn more here!

Applications often require 4-6 weeks for processing. If you require expedited processing, please explain below.

Section 9 - Dues Payment

Please carefully read the instructions below. Note that any application that requires a dues payment will be placed on hold if dues are not paid. Note: Even if you are a member-in-training applicant and owe no dues, you still need to subscribe to the member-in-training pricing plan ($0) for your membership to activate! Note #2: Check the "Guest Checkout" box when prompted.

Instructions for Paying Your Dues:

1. Noting the member category that applies to you (see your response in Section 7 above), choose the applicable pricing plan here. Note: You will see several pricing plans not open to new members so please only choose the plan for the membership category you chose in Section 7 above.

2. A "Checkout" menu appears next. Complete all the required information. You will see a order summary in the box on the right side.

3. In the "Order Summary", where it says "Enter a Coupon (or promo) Code", Enter "2025NEWMBR"

4. Scroll to the bottom of the box where you will see a black box labeled "Continue". Click on this box.

5. You will next be asked to select your (electronic only) payment method and the option to pay as a guest, which you should select.

6. Click on the "Buy Now" box.

7. Click the "Submit" button below and you are all set!

I have just subscribed online to an ASAP approved membership plan and paid the required (if any) dues.

Thank you for your application! We will review it shortly and advise you of your membership status soon. If you desire expedited application processing, please specify your reason below. Otherwise, it generally taks 4-6 weeks to process your application. If you have any questions/comments about the application process, please write them below or contact our executive office and we will be happy to help!

Expedited Application Rationale: