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The Virginia Society for Clinical Social Work, Inc.
Promoting clinical social work education and practice since 1976
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VSCSW New Member Application
 Complete the information for the membership category for which you are eligible.
 Please note: the VSCSW does NOT store Credit Card or Social Security information on this Website.
MEMBERSHIP CATEGORIES:
Full: ($150/yr)  
 An individual who is a Licensed Clinical Social Worker currently licensed in good standing by the Commonwealth of Virginia. 
 Please send a copy of your license to the address below. 
 Highest graduate degree:   Year:  
 School:  
 VA License Number:  
 Other Licensed States:  


Associate: ($115/yr)  
  A person who meets the Society's educational requirements for Full Membership, but has not acheived licensure by the Commonwealth of Virginia.  
  Highest graduate degree:   Year:  
  School:  


New Professional: ($50/yr)  
  Applications received from MSW students graduating from accredited schools of social work within six months after graduation, are eligible for this class of membership, from a one-year period following their graduation.  
  Year of Graduation:  
  School:  


Student: ($40/yr)  
  Anticipated Degree:  
  Anticipated Year of Graduation:  
  Full Time Student? Yes No  
  Name of School in which you are enrolled in a Master's or Doctorate Clinical Social Work program.  
   
  Student I.D. Number:  


Affiliate: ($65/yr)  
  A Person who is a Full Member of a clinical society in another jurisdiction who wishes to affiliate with the Virginia State Society, with the option of joining the Guild.
Please send a copy of your license to the address below.

A Person living abroad or in a jurisdiction where no clinical society exists who otherwise qualifies for membership.
Graduate Degree:
School:
Year:
Out-of-State resident? Yes No

A Person who is Retired from active clinical practice.
Date of Retirement:


CSW Guild Dues: ($120/yr)
    Clinical Social Work Guild for Full, Associate and Affiliate members who wish to join the CSW Guild
    An Organization affiliated with OPEIU and AFL-CIO.
    Social Security Number  
    Date of Birth:   Month:    Day: Year:
    (Required for Guild membership only)

VSCSW Lobbyist Fund Donation:     $

Current Home and Professional Information
(will be included in the Directory)

Home Address: 
First:
Middle:
Last:
Suffix:
Street:
City:
State:
Zip:
Phone:
Fax:
Cell/Mobile:
Birthday: Month:    Day: Year:
Email:
Districts: Congress#: VA Senate#: VA House#:

First Work Address:
Biz/Org Name:
Street:
City:
State:
Zip:
Phone:
Fax:

Second Work Address:
Biz/Org Name:
Street:
City:
State:
Zip:
Phone:
Fax:

Titles: (Check all that apply)
LCSW   MSW   BCD   DCSW   CSAC   LSATP  
DSW   RPT   EDU   PhD   CAC MD
Mailing Preference:
Home  
Office 1  
Office 2  
Clinical Practice Information:
This information will be listed in the Directory
Full-Time Private Practice  
Part-Time Private Practice  
 
Check all that apply  
Daytime Hours Evening Hours
Insurance Coverage Sliding Fee Scale
Saturday Hours Sunday Hours
Children Adolescents
Adults Geriatric
Individuals Couples
Families Groups

Professional Experience: (Clinical social work and related experience)
Dates Name of Business/Organization Job Description
Please indicate which chapter you wish to join:
Richmond   Roanoke   Blue Ridge   Eastern Region  

I would be interested in active participation with the following Society activities:
Conference Education Fundraising
Legislative Membership Mentoring
Newsletter Public Relations Representative to advisory boards
References: Please provide the name and phone number(s) of a person who can verify the information in this application and/or the name of any member who invited you to apply:
Other Affiliations:
VSCSW.ORG Account Security:
Username: (Will be checked for duplicates)
 
New Password:  
Verify Password:  
Affirmation: By submitting this application, I affirm that the above information is a true account of my training and experience, and I agree to be bound by the CSWF Code of Ethics.

Mail copies of current practice licenses to:
C.J. Reiner
10106-C Palace Way
Richmond, VA 23238
 
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