Reg-Sub

SBSM Member#

First Name *

Last Name *

Suffix

Degree(s)

Credentials

Certificates

Gender

Female

Male

Race

Date of Birth

Organization

Address *

Address2

City *

State *

Postal Code

Country *

Personal Email *

Personal Phone *

Are you associated with a BSM Training Program?

Yes

No

Which program are you associated with?

Receive BSM Journal by Mail? *

Yes

No

Permission to post listing details on the SBSM website

Yes

No

Contact Name

Contact Title

Contact Phone

Contact Email

Business/Institution Name

Business Website

Business Email

Business Phone

Business Address

City

State/Province

Country

Business Social Media

Comments

List License(s) & States

Licensed outside the United States?

Yes

No

Provide Location & License

Telehealth States

Licensed for telehealth outside the United States?

Yes

No

Provide Location & License

Accept major insurances?

Yes

No

Describe billing policies

How did you hear about us?

Agreement Items

I attest that all posted degrees/certifications/licenses are accurate and current

As a member of the SBSM, I agree to abide by the ethical and professional standards of conduct.

Price

$

Payment Method

Credit Card

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Holder Name*

Regular Membership - 365 Day Term Membership

Existing user? Please login

Section 1 - Biographical Data (Internal SBSM Usage)

Section 2 - Business/Organizational Data (Public Profile - Publicly Shared (Optional)

Provider Information - Primary Contact Details

Provider/Business Information

Licensing

Telehealth

Insurance/Accepted Payments

Referral Source

Agreement

Payment Information