Join CSSGO

Name

First Name

Last Name

Title/Credentials

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Title, Present Position, or Area of Study

Name of Employing Organization or University

Relevant Clinical Training and Experience

Include Date, Organization and Nature of Training

Conference Experience as a Member

Include Date, Hosting Organization, Location, and Director/Small Group Consultant (if known)

Conference Experience as Staff

Include Date, Hosting Organiation and Director

Other Relevant Group Experience

List group therapy experiences, positions, research activites, relevant presentations and publication, etc

Please provide the name and contact information of two professional colleagues or associates who are familiar with your group relations work

Reference #1 Name

First Name

Last Name

Reference #1 Contact

Reference #2 Name

First Name

Last Name

Reference #2 Contact

Those who have been members (or on the staff) of at least two group relations conferences held under the auspices of the A.K. Rice Institute, or conferences designated by the CCSGO Board as equivalent, are eligible for Associate membership in CCSGO.