ASAP Membership Application - 2026-2027 Version

Individual Application Form

This is an INDIVIDUAL membership application form.

If you are joining as part of a special "Organizational Affiliate Membership" arrangement, please STOP HERE and do not complete this application (your facility administrator will submit your name along with the organizational membership application, so an individual application is not required).

For any individual member applicants:

Please complete all relevant sections and click "submit".

Questions with asterisks (*) are required.

Once submitted, our Executive Office will forward your application to the Membership committee for review.

ASAP may check references and may make inquiries about any applicant’s training and professional qualifications, if deemed necessary.

PLEASE NOTE!!! - You must complete all "required" sections (marked with an asterisk) or rejection will occur. If, after two attempts you are unable to submit the application, please try the alternative application.

If you answered "other" above, or if an ASAP member or colleague referred you, please write your answer or their name below so we may thank them personally!

If an ASAP Member referred you, please name them here so we may thank them!

What is your Preferred (non-institutional if possible) Email Address (institutional ones more likely to have firewalls, etc)

What is your Last Name?

What is your First Name?

What is your terminal degree credential abbreviation (M.D., D.O., Ph.D., Masters Degree, ARNP, etc)? If a Medical or Graduate Student, please note.

What is your Birth Date? Note: This is not shared; we use it to compute future fellow and life status eligibility only

What is your PREFERRED Phone Number? Enter your country code (if non-USA), area code, and preferred phone number

What are the Last 4 Digits of Social Security Number? (If non USA Citizen, enter 0000)

What is your mailing address (Street or PO Box, City, State, Zip or Mail Code, and Country (if not US)?

Section 2, PHYSICIANS (and Medical Students) ONLY - If you are NOT a physician/medical student, SKIP this section!

If you are NOT a -physician/medical student, please SKIP to SECTION 4.

Where (name of school and location) did you (or will you, if a student) complete your basic Medical Education?

When did you (or will you, if a student) complete your basic medical education?

Where did you complete your residency (facility and location)? If student or graduated but awaiting PGY, leave blank

If not a general psychiatry residency, please specify below (skip otherwise):

Date of completion of residency training (if still in training or a student, please put your anticipated graduation). Skip if graduated but awaiting PGY

Additional Post Graduate Training & Degrees (specify type, location, with dates). If graduated and awaiting PGY, explain here - skip if not applicable

Additional Board Certification Information

Current Active Medical License (state, number, exp. date) - if not required to have a license, please state reason below.

Are you an active APA/CPA (Canadian Psychiatric Association) Member? Check applicable boxes (as an APA affiliated society, APA/CPA membership is typically required)

yes

no - if no, you must complete one of the boxes below in addition to this one

I meet eligibility criteria for APA/CPA but for personal reasons have chosen not to join or remain

I do not meet eligibility criteria for APA/CPA and have left a detailed explanation below

I am not sure. Please review criteria: https://psychiatry.org/membership/join-apa/general-members

I am not a psychiatrist, but am an active member of my discipline's national society

other - see next section

Please list other professional organizations in which you are actively involved:

SECTION 3 - Additional Section for all RESIDENTS, MEDICAL STUDENTS, GRADUATES AWAITING PGY (RESIDENCY) ACCEPTANCE (Including IMG's & International Residents), AND FELLOWS ONLY: Please complete this section in addition to section 2

All other applicants, please SKIP this section and proceed to SECTION 4 or SECTION 5 as appropriate. NOTE: We must verify your status with your training director or (if medical student) your office of academic affairs/admissions. If you are a graduate awaiting acceptance to residency, please list program(s) you have applied to (or if none, explain). Your application cannot be processed if you do not provide this information and the contact information of the institution official. Thank you. ASAP's offer to waive first year membership dues, and to extend an 75% discount for subsequent years as a trainee, for individuals in training or awaiting the start of residency is subject to verification of graduation or program completion dates. For any applicant who has graduated medical school yet not accepted into residency yet, membership dues are waived for only one year, after which the applicant will be required to update their training status for continued dues discounts or waiver eligibility. IMG's and International Physicians awaiting a training program's acceptance are included in this category.

Please upload any supporting documents relating to the questions above (not a requirement, but helpful. Documents may be requested later by Membership Committee)

Upload your file

Choose a file or drag and drop one here.

Please indicate the name and location of the institution where you are presently in training or have applied:

Please indicate the date you expect to complete your training program. If you have graduated medical school but not been accepted to residency yet, please skip:

Please provide your training director with this link to complete a brief online form attesting to your current training status and graduation date: https://forms.gle/AufFFUD251LdoNCE9

Yes, I will share this link with my training director

No, I will ask my training director to send an email directly to: asapadolpsych@gmail.com

Please indicate the name of your training director - if Medical Student, the contact at your Office of Academic Affairs

Please give us your training director's email contact information (for purposes of verifying Training status only) - If not yet in residency, please state this:

Now - subscribe to the Member in Training Pricing Plan. Copy and paste this URL into your browser: https://www.adolescentpsychiatry.org/plans-pricing

SECTION 4 - NON-PHYSICIANS ONLY: Complete this section

All other applicants, please SKIP this section and go to SECTION 5

Graduate School (with dates and degree awarded)

Post Graduate Training & Degrees/Certifications (with dates) - skip if not applicable

Internship (if any, with dates) - skip if not applicable

Non-Physician currently-active Certifications/Licenses and States:

Additional Training, Degrees, and Dates:

I am a member of my discipline’s National Society/Association:

Yes

I am eligible for membership but for personal reasons choose not to join or remain a member

I am not eligible for membership

Professional Society/Association Membership(s):

Other Professional Societies (skip if none):

Please upload any supporting documents relating to the Physician or Non-Physician sections above (not required, but helpful; may be requested later by Membership Committee)

Upload your file

Choose a file or drag and drop one here.

SECTION 5: Professional References (If you are applying for Member-In-Training Status, please SKIP this section)

Please complete this section in its entirety - The membership committee reserves the right to ask you to produce written reference letters if requested. If you are applying for membership-in-training status, please skip this section. References are NOT REQUIRED, but they are RECOMMENDED to expedite your application process.

References will expedite your membership application if provided at the time of application and are easiest submitted online using this link, designed specifically for your references to complete easily.

If you prefer, you may copy and paste this URL into your reference request letter: https://forms.gle/GFqxecfbAF6Q4geXA

Otherwise, written letters may be submitted via email to: asapadolpsych@gmail.com

WITHIN THE PAST 12 MONTHS, have you been certified by the American Board of Adolescent Psychiatry (ABAP) or do you have an ABAP application in progress? If yes, we wil use those references and you may skip to Section 6

Yes

If you were you referred by or know an ASAP Member. please list their name. We will contact them on your behalf and you do not need to send any other references unless we contact you for them and therefore should skip the remainder of this section.

Optional - List Reference #1 (name, address, city, state, zip code, email address, and phone numbers) - you may be asked to supply this informaiton later however if not provided now.

Optional - List Reference #2 (name, address, city, state, zip code, email address, and phone numbers) - you may be asked to supply this informaiton later however if not provided now.

If you have letters of reference already available or wish to obtain them to submit with this application, please upload them here (letters are not required but recommended in order to facilitate membership committee approval)

Upload your file

Choose a file or drag and drop one here.

SECTION 6 - Questions and Attestations

All applicants must complete this section.

Have you ever been found at fault by any licensing board or professional ethics committee, or are you now under investigation by any such group?

Yes (please summarize the issue, outcome, and consequences in the section below)

If you answered "yes" above, please explain the action and outcomes/decisions.

Please upload any supporting documentation pertaining to the above question here (optional, skip if not applicable)

Upload your file

Choose a file or drag and drop one here.

I confirm that the information provided on this application is true. I authorize ASAP to contact the above-named references, academic institutions, and organizations if necessary to verify or obtain information regarding my application for membership and/or confirmation of my education, credentials, and/or membership, and hereby release the above named to provide information for this purpose.

Today's Date

Your Signature

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SECTION 7 - Membership Category

Please complete this section in its entirety.

Choose your membership classification below:

Regular Membership (Psychiatrist)

Member-in-Training (Residents, Med/Grad Students, Fellows) - FREE MEMBERSHIP for First year)

Early Career Psychiatrist (First 5 years post completing of Residency/Fellowship)

Associate Membership (Non psychiatrist physicians, non-physicians with graduate degrees)

Organizational Membership (see below)

Member-in-Training (Graduated but awaiting residency acceptance) - dues waived w/annual verification

ASAP offers several membership categories. Please read about them on our website and then make your request below.

If you are a member of an organization or institution, you should consider the option of organizational membership which allows all clinical staff of your organization to automatically become ASAP members at no charge to them but rather via a negotiated fee paid by their organization on behalf of all of its members. Please have our administrator contact us about this option for you and your colleagues!

ASAP Membership is presently offered at no charge to members in training (medical or graduate students, residents, fellows, or physicians awaiting residency match) for their first year of membership. Subsequent years are billed at 25% of the regular rate unless the membership committee waives this requirement any given year, and/or if the trainee has demonstrated active involvement in ASAP affairs (submitting a blog entry, entering a poster or paper in our annual competition, participating on a committee, assisting with clerical work, reviewing books, etc.). Graduates awaiting acceptance to residency are considered "in training" and therefore eligible for no-charge dues their first year subject to annual verification.

Any new members who join in the first half of the year will receive ASAP Rewards Points to offset the shortened dues year (since all members renew their membership on January 1). Those joining in the latter portion of the year will have their membership extended at no charge to the end of the subsequent year.

If you selected "organizational membership" above, please list the name and contact information for your facility administrator so we may contact him/her to begin the process involved.

SECTION 8 - ASAP Mentoring Program & Other Opportunities for New Members

The American Society for Adolescent Psychiatry offers Mentoring to new members although it is not required. Mentees are paired with an ASAP Former President, current officer, and/or a member with many years of experience in ASAP as schedules permit. Mentors help new members "find their way" in ASAP and to build their credentials and experience through maximal pairing of their interests with opportunities in and outside of ASAP in the field of Adolescent and Young Adult Psychiatry. We leave it entirely up to the mentor and mentee to determine their focus and frequency of any meetings as well as the duration of their relationship. Members-in-Training are offered a specialized hybrid mentoring experience that combines individual and group activities as arranged. THERE IS NO CHARGE FOR MENTORING!

If you are interested in receiving mentoring, please complete this online form at this time.

(If you encounter problems or repeated error messages with the above form, but only if so, please use this alternative online form)

Do you have an interest in assisting ASAP by serving on one of our working committees? If so, please check any that apply and we will contact you once your application is approved. Volunteers are eligible for discounted dues or event registration fees.

Administration/Finance/Operations Committee

Membership Committee

Marketing and Media Oversight Committee

Annual Program Committee

Strategic Planning/Bylaws Committee

Ethics Committee

Other (please add at the end of this section)

Please let us know any other interest areas or committees you may be interested in!

Board Certification in Adolescent and Young Adult Psychiatry Opportunity!

Did you know that ASAP offers Board Certification in Adolescent and Young Adult Psychiatry through our hosted American Board of Adolescent Psychiatry (ABAP)? This specialty certification does not require a fellowship, and is most appropriate for General Psychiatrists working with teens and young adults in a variety of settings (traditional, residential, correctional, college, military). Learn more here!

Applications often require 4-6 weeks for processing. If you require expedited processing, please explain below.

Section 9 - Dues Payment

Please carefully read the instructions below. Note that any application that requires a dues payment will be placed on hold if dues are not paid. Note: Even if you are a member-in-training applicant and owe no dues, you still need to subscribe to the member-in-training pricing plan ($0) for your membership to activate! Note #2: Check the "Guest Checkout" box when prompted.

Skip this section if you desire a 30 day free trial membership (only open to ECP, Associate, and Regular Members)

Instructions for Paying Your Dues:

1. Noting the member category that applies to you (see your response in Section 7 above), choose the applicable pricing plan here. Note: You will see several pricing plans not open to new members so please only choose the plan for the membership category you chose in Section 7 above.

2. A "Checkout" menu appears next. Complete all the required information. You will see a order summary in the box on the right side.

3. In the "Order Summary", where it says "Enter a Coupon (or promo) Code", enter any discount coupon codes in your possession

4. Scroll to the bottom of the box where you will see a black box labeled "Continue". Click on this box.

5. You will next be asked to select your (electronic only) payment method and the option to pay as a guest, which you should select.

6. Click on the "Buy Now" box.

7. Click the "Submit" button below and you are all set!

I have just subscribed online to an ASAP approved membership plan and paid the required (if any) dues.

Thank you for your application! We will review it shortly and advise you of your membership status soon. If you desire expedited application processing, please specify your reason below. Otherwise, it generally taks 4-6 weeks to process your application. If you have any questions/comments about the application process, please write them below or contact our executive office and we will be happy to help!

Expedited Application Rationale: