First, print this application form on your printer.

Make checks out to Mental Health Counselors of Greater Rochester and send to

Susan Roxin, 23 Avon Road, Rochester, NY 14625
Any questions please call her at 585-385-4907 or sfroxin@yahoo.com

Professional Membership- $30.00 Student Membership- $15.00
Associate Membership- $15.00

All members of Mental Health Counselors of Greater Rochester are also required

to be members of NYMHCA. NYMHCA Membership #________________

Name_____________________________________________

Home Address____________________________________________________

________________________________________________________________
Highest degree___________________________
Graduated from:_______________________________Year Graduated____
If student, institution attending__________________________
Anticipated date of graduation________________________
Type of Work_____________________________________
Work Address____________________________________________________

________________________________________________________________
Home Telephone:______________________
Work Telephone:_______________________
Cell Phone:___________________________
Email address:_________________________________________________
Any specialty you have or topic you may be willing to share with your chapter at a local meeting?

_____________________________________________________________________________

Programs/topics you are interested in knowing more about?______________________________

_____________________________________________________________________________

We are creating a member directory on our website. Would you like to be listed in our online

member directory?_________________________________________

Can we share the following contact information?
Name
Phone
Email

Members who are interested in being in the directory may submit a picture (jpeg.) to

mardierossi@gmail.com, and include a description of their professional work/experience.

(75 word limit) ______________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________