Application Form — Southern Psychiatric Association

After you submit the below application, you’ll be directed to the application payment page.

If you prefer to print and mail in your application, you may access the PDF application here.

New Member Application

Name

First Name

Last Name

Office address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday

YYYY

Place of birth

Spouse or nearest relative's name

Spouse or nearest relative's address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Subspecialty(ies):

Medical school graduation

Name of school and date

State, provinces, or foreign countries in which licensed to practice medicine

Professional training in psychiatric institutions

Give names, exact addresses of institutions in which appointments have been held, with exact dates of service, and official titles

Membership in scientific societies

Indicate the name of local, county, state or national scientific, particularly medical societies, in which membership is held

Present hospital affiliations and rank

Teaching appointments

Give title and department

Have you practiced psychiatry in private practice full time??

Specify years and location

Have you practiced psychiatry in private practice part time??

Specify years and location

Community service

Please specify any work on community and public committees

Are you a member of the American Psychiatric Association?

Yes

Are you a fellow of the American Psychiatric Association?

Yes

If applicable, what is your APA District Branch?

Are you certified by the American Board of Psychiatry and Neurology?

If yes, specify if you are certified in psychiatry or neurology and the year of certification.

Are you certified in other medical specialties?

Please specify

Medical papers published

Give titles of papers published with volume and date of journals

Name and address of member or Fellow of the Southern Psychiatric Association who wrote your letter of recommendation

Please email the letter of recommendation to: JBryan@sheppardpratt.org

Have you ever been deprived of your license to practice or expelled from a medical society?

Yes

If yes, please explain

One last item

I agree to hold the Southern Psychiatric Association, its members, officers, and agents free from any damage or complaint by reason of any action they or any of them may make in connection with this application. I have read the Constitution and bylaws.