Membership Application

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Please fill out the form below to join MMHCA

Membership Level:

Student - $65

Regular - $100

Supervisor/Counselor Educator - $150

Lifetime - $1000

Senior/Retired (65+)

The membership you have selected will automatically renew.

First Name: Last Name: Home Phone: Email: Home Address: City: State: Zip: - Degrees (separate with commas) Licenses (separate with commas) Are you a Qualified Supervisor of LLPCs?

Yes

To manage your MMHCA account (i.e., view donation history, renew membership, etc.), please create a login name and password below. Your password must be at least eight characters long, and contain at least one number.

To renew your membership, please sign in. If needed, create your login and password by entering your email under "Recover Account" below and return to the form to sign in.

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