Membership Information Form

    We strive to keep members' information as up to date as possible. If you are a current CoPGTP member, please complete the following form and we will update the information for you. If you have any questions, feel free to email us at copgtpsec@gmail.com.

    Your Name and Email Address*

    (This is so we can contact you, it will not appear on the site):

    First Name:

    Last Name:

    Email Address:

    This is*:

    A new program listingAn update to my current listing

    Your Program Name*:

    Program Type:

    You may either enter in all the current information below, or if you have a small update, simply include the new information that you would like updated.

    Primary Contact Information:

    (e.g. name, address, email, phone)

    Director of Psychology Training:

    Geropsychology Supervisor(s):

    Website Address:

    Membership / Certification:

    APA AccreditedAPPIC Member

    Geropsychology Training Opportunities / Settings:

    Outpatient Mental Health ClinicNeuropsychology / Memory ClinicCommunity Living CenterHome Based Health CarePrimary CareInpatient Geropsychiatry/Mental HealthPhysical / Cognitive RehabilitationCaregiver Support ServicesHospice / Palliative CareTelehealth / TelemedicineTraining in Supervision of Interns / Practicum StudentsOther

    Other:

    Format of Geropsychology Training:

    Specialty Track in GeropsychologyMajor RotationMinor RotationOpportunities to work with older adults included in other rotations

    Faculty Clinical/Research Interests: