Alumni Membership Renewal

Personal Information

First Name*

Last Name*

Degree

Email*

Ackerman Graduation Year*

Address*

City*

State*

Zip code*

Country*

Professional Information

Professional Title

Name of Organization/Agency

Work Address (with City, State, and Zip Code)

Office Phone

Website

Private Practice Information: to be listed on Ackerman Website and with the Intake Department

Would you like private practice referrals?*

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No *If no, please skip this section.

Is your professional and private practice address/phone number the same?

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Would you like your email address to be listed on our website?

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Private Practice Address

City

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Zip Code

Private Practice Phone

Private Practice Email

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Please list fee range

I accept insurance

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Ackerman Institute Alumni Dues

Alumni Dues

$65.00

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Mailing List

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By Mail: To update information and pay dues via check, please print and complete this form and enclose your check to the Ackerman Institute. Please do not fill out the online form. Mail to Attn: Nicole Mak, 936 Broadway, 2nd Fl, New York, NY 10010.

Alumni Membership Renewal

Please fill out the following form to add or update your information.

Personal Information

Professional Information

Private Practice Information: to be listed on Ackerman Website and with the Intake Department

Ackerman Institute Alumni Dues