Please include ONLY information that can be posted on the Member's Only part of the MNS website, and that can be published in the MNS Member Directory that will be sent to all members. DO NOT INCLUDE private contact information that you do not wish to be made available to the public. Updated personal contact information that will not be made available can be listed below first.

Private Contact Information:

Name:

Street Address:

City/Town: State: Zip Code:

Email Address:

Tel. Number(s):  

Do you wish to have your name removed from the proposed MNS listserve at this time?
   Yes

   No (you can remove your name at any future time as well).

Contact Information for MNS Directory / Members' Only section:

Name:

Credentials:

Degree:

Board certification:

license #:

Department:

Institution / Agency:

Street Address (where you prefer to receive mail): 

City/Town:   State:  Zip Code:

Email Address:

Telephone Number(s):  work:   home:  cell:

Please describe your practice, listing any areas of specialization (clinical conditions and specialized interventions) and populations served (ages) for each.

 

Billing and Reimbursement:
(please indicate any insurances you do not accept or other relevant issues that would assist someone making a referral).

 


Please indicate whether you wish to have your information posted on:

1. The Member's Only section of the website
   Yes

   No

2. The MNS Membership Directory
   Yes

   No

Please indicate whether you are interested in listing your contact information in the MNS Referral Database portion of the website (review of your information on-line prior to making the listing available to the public will be possible).
   Yes

   No

Any further comments / suggestions regarding the above issues, or other issues of relevance to
MNS?
 

Suggestions for CE lecture series speakers /topics (contact information would be helpful):

 

Are you willing to be contacted for volunteer activities?

   Yes