Msstd Application

Midwest Society for the Study of Trauma and Dissociation/ Membership ApplicationPlease list your work contact information below and your preferred email address. Most of our exchange will be done via email but it’s nice to have a work address on file as well. An online directory of members will be posted on our web site, www.msstd.info. for those that wish to be included. (It may take a while for your information to be posted, please be patient.) Please indicate below your preference to be listed and the information you’d like posted in the online directory. Please include all requested information on this application, if you do not want some or all of your information listed in the directory, please indicate this preference accordingly.

Your name

Name and Credentials

If student list graduate program you are attending

 Telephone for contact   

 Email Address 

I've enclosed my contact information below but i do NOT want any information posted in the online directory

(Type your name here)

Please post what you would like posted in the online directory

Place of Employment

Name (With appropriate credential abbreviations)

Work Adress
Work Phone
Work Fax

Web Site
Do you work with dissociative disorders, including DID, and is it ok to idicate this

(Optional): Home address and phone #, this info. WILL NOT be posted to the online directory

Are you a member of ISSTD, the international organization

What are your areas of interest and specialization

If you have other areas of specialization, or interest, please state them here.

What therapy population do you prefer to work with?
Email: wklemke@aol.com, Fax 866-899-1241, Phone 320-558-6037
Wendy K Lemke, MS LP, P.O 434, Clearwater, MN 55320

 

 

Webmaster: Luke Lemke, Email - webmaster@msstd.info

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