APPLICATION FOR FELLOW STATUS

The ASGPP is committed to fostering national and international cooperation of all who are concerned with the theory and practice of psychodrama, sociometry, and group psychotherapy.

Anyone who has been an active member of the Society for five or more consecutive years and has made a significant contribution to the field or to the Society may be made a Fellow by a vote of two thirds of the Executive Council.

Name ____________________________________________________

Highest Degree ______________ Diplomate _________ Psychodrama Certification _______

Address_______________________________________________________________________

City____________________________ State____________ Zip_______________

Phone ______________________________________ FAX ______________________________

E-mail _____________________________________________

License (if any):

State Year Field

____________ _________ _______________________

____________ _________ _______________________

Date of initial membership in American Society of Group Psychotherapy and Psychodrama ______

Experience in the practice of (or research in) group psychotherapy, psychodrama, and/or sociometry and significant contributions in these areas (attach Curriculum Vitae and any other information documenting criteria):

References:

Name______________________________________________________________

Address_______________________________________________________________________

City____________________________ State____________ Zip_______________

Phone ______________________________________ FAX ______________________________

E-mail _____________________________________________

Who recommended you? _______________________________________________________

Nominations must be postmarked no later than:

August 1

Please mail this form to the national office:

American Society of Group Psychotherapy and Psychodrama

301 N. Harrison Street Suite 508 Princeton, NJ 08540