New BRAIN Member Questionnaire

New BRAIN members are accepted based on information submitted from the below form. The only other criterion to join BRAIN is that the new member be a licensed psychologist.

If you would like to join the BRAIN study group, please complete the following form. After receiving this information, we will send an email to the new member that will include an introductory welcome letter and forume registration information. We will subsequently post the biosketches of new members to the BRAIN forume as a means of introducing them to the group.

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Race/Ethnicity (Optional)

Sex/Gender(Required)

Graduate University(Required)

Year Graduated(Required)

Please enter a number from 1970 to 2030.

Degree(Required)

Other Degree(Required)

Forensic Training(Required)

Internship(Required)

Postdoctoral Fellowship(Required)

Professional Identity(Required)

State or Province(Required)

Work Status(Required)

Primary Practice Setting(Required)

Memberships

Please check all that apply or leave empty if none.

AACN

INS

NAN

APA Division 40

Other

Other Membership(s)(Required)

Areas of Interest (Clinical)(Required)

Areas of Interest (Research)(Required)

Years in Practice(Required)

Please enter a number from 0 to 60.

Year Applied or Applying to ABPP(Required)

Please enter a number from 1980 to 2030.

Comments

This field is for validation purposes and should be left unchanged.