LOUISIANA COUNSELING ASSOCIATION MEMBERSHIP FORM Please mail completed application and payment to: Louisiana Counseling Association. 353 Leo Avenue. Shreveport, LA 71105

______First MI Last

❏ Mr. ❏ Ms. ❏ Dr. Other:______

❏ Renewing ❏ New Member ❏Reinstate

Preferred Email: ______

❏ Home ❏ Work

Office Phone: ______

Home/Cell Phone: ______

Mailing Address: ❏ Home ❏ Work

Street:______

City: ______Parish:______

State: ______Zip: ______

❏ Please list my name in the LCA Find-a-Counselor Directory ❏ LPC ❏ LMFT ❏ NCC, NBCC, NCSC

❏ Louisiana Legislative Districts: Senate ____ House____

❏Fluent in another language?______

❏ *Students --Please provide the following: University ______

Referring Professor’s Name:______

Membership Fees: Membership is renewed annually from date of initial application and is tax-deductible. You must be a LCA member to join a division. LCA members must join at least one division. Membership is non-refundable.

Membership / Fee / Paid
Professional / $60.00
Counselor Intern / $40.00*
Student / $35.00
Retired / $35.00
Emeritus / Exempt
LSCA / $10.00
LSCA Student / $5.00
LACES / $10.00
LACES Student / $5.00
LCDA / $10.00
LCDA Retired / $5.00
LCDA Student / $5.00
LAMFC / $10.00
LAMFC Retired / $5.00
LAMFC Student / $5.00
LASERVIC / $10.00
LASERVIC Student / $5.00
LCCA / $5.00
LAAOC / $5.00
LAAOC Student / $3.00
LAMCD / $10.00
LAMCD Student / $5.00
LMHCA / $12.00
LMHCA Student / $6.00
ALGBTIC / $5.00
LCSJ / $5.00
PLCA / $5.00
Legislative Trust Fund
Scholarship Trust Fund
Research Trust Fund
Legislative Action
Total:

*Includes a membership in PLCA

Payment Method: ❏ Enclosed is $______❏Please Charge $______to my: ❏Visa ❏MasterCard ❏Amex ❏Discover Credit Card # ______Exp. Date ______Cardholder’s Signature ______

DIVISIONS:

LOUISIANA SCHOOL COUNSELORS ASSOCIATION (LSCA)

LOUISIANA ASSOCIATION FOR COUNSELOR EDUCATION AND SUPERVISION (LACES)

LOUISIANA CAREER DEVELOPMENT ASSOCIATION (LCDA)

LOUISIANA ASSOCIATION OF MARRIAGE AND FAMILY COUNSELORS (LAMFC)

LOUISIANA ASSOCIATION FOR SPIRITUAL, RELIGIOUS, AND ETHICAL VALUES IN COUNSELING (LASERVIC)

LOUISIANA COLLEGE COUNSELING ASSOCIATION (LCCA)

LOUISIANA ASSOCIATION OF ADDICTION AND OFFENDER COUNSELORS (LAAOC)

LOUISIANA ASSOCIATION FOR MULTI-CULTURAL COUNSELING AND DEVELOPMENT (LAMCD)

LOUISIANA MENTAL HEALTH COUNSELORS ASSOCIATION (LMHCA)

ASSOCIATION FOR GAY, LESBIAN, AND BISEXUAL ISSUES OF LOUISIANA (ALGBTIC OF LOUISIANA)

LOUISIANA COUNSELORS FOR SOCIAL JUSTICE (LCSJ)

ORGANIZATIONAL AFFILIATE:

Provisional Counselor Association of LA (former CIAL)