Membership Form

New MembershipMembership Renewal

Please complete and sign below:

First Name MI Last Name

Affiliation / Organization:

Street   Suite/Apt. No.

City State Zip

Work Phone   Cell/Personal Phone

Email Address

Birth year (for Life membership status)

What year did you join IGPS?

Today's date: 10/13/2019

New Members – Please provide documentation as listed below:

Clinical membership: Proof of Clinical Membership in AGPA OR CGP Certificate and a copy of your current license
OR copy of highest professional degree and copy of current license and Affidavit and two Endorsements and Profile Form (forms available at www.ilgps.org or via email at igpsinfo@aol.com)

Associate membership: Provide copy of highest professional degree and copy of current license and Profile Form

Please read and sign (if submitting this form online, the applicant automatically agrees with the following statement): I recognize that I am obligated to report to IGPS any changes in the status of my license or changes that might affect my membership.

Membership level details

  • Clinical: Clinical professional who holds a CGP, or non-CGP professional with a Master’s degree, Clinical license, and 300+ hours of group therapy leadership and at least 75 hours of qualified group psychotherapy supervision

  • Associate Professional with a Master’s degree or higher in the mental health field and licensure in their respective discipline
  • Affiliate Individuals with experience as group therapy leaders or interested in practice and development of group psychotherapy
  • Student Currently in a graduate degree or residency program or post-graduate program of 1+ years in duration.
  • Life 15+ years IGPS Clinical membership and at least 65 years of age. Life members are exempt from all dues, but will need to attest (below) in order to maintain the benefits of a Life Clinical Member as stated in the IGPS Bylaws
  • Retired Professional retired from practice but still wishing to participate in IGPS activities


Membership Levels:



In addition to my membership dues, I’d like to include a contribution for:

Ariadne P. Beck Scholarship Fund (supports IGPS members attending the national AGPA annual meeting) $

Hylene S. Dublin Scholarship Fund (supports IGPS members attending IGPS conferences) $

IGPS General Fund $

Total payment: $




I hereby attest that my clinical license is current and in good standing and that I meet the qualifications for the membership level indicated above. I recognize that I am obligated to report to IGPS any changes in the status of my license or changes that might affect my membership.

Please complete and submit this form, or print and send completing it via snail mail to the address listed below. Please direct any questions to igpsinfo@aol.com

Illinois Group Psychotherapy Society
P.O. Box 28538
Green Bay, WI 54304-5388


Signature Section - if you are submitting the application via mail.


License No.: Type: State:

License No.: Type: State:

Expiration Date:

Signature (My name entered here constitutes my signature and agreement to adhere to the renewal requirements of the membership level selected.):