Institute for Marital and Sexual Therapy Application

The Institute for Marital
and Sexual Therapy
P.O. Box 210278
Chula Vista, CA. 91921-0278
Fax: (619)656-8996

Application Form to join IMST and be listed in "Sex Therapist" Directory

Join a growing number of therapists that find this directory the best referral source for their practice. You will be charged a renewable fee of $100/year. You will find that this fee will more than be recovered in the first few months of your directory posting. We are number one in most search engines for "sexual therapy" and "therapist's directory".

FAX : Fill out the order form below, print it and fax it to 619-656-8996. Email photo to drrtc2@cox.net
Mail : Fill out the order form below by "cut and paste", print it and mail it with your photo to:
P.O. Box 210278, Chula Vista, CA 91921-0278.
Email: : Fill out the form below and click the "Send Your Application" button. NOTE: Your photo must be received via email : drrtc2@cox.net or mail. The photo can be sent as a .jpg image or any compatible Photoshop 6 image. It will not be returned if sent by mail. Your credit card will only be charged $100 after the web page is posted, you have been contacted and approve the content and layout.

Your name:
Gender:	M F
Occupation:
Address:
City:		State:
Zip Code:		Country:
Telephone:		Fax:
Email address:
Payment:	Check Credit Card
Credit Card:
Cardholder Name:
Credit Card #:		Expires:

The information that you supply in the following five boxes will allow us to create a web page for you.

Please be a thorough as possible, do not be shy. You have plenty of space.

Credentials and Affiliations (list up to six).

Specialty Areas and Services (list up to eight).

Notable accomplishments.

Current books in publications; do you have a current web site and what is the name?.

Comments : include any special ideas that you want on your web page, such as mission statement.

Your order is processed after credit card payment is authorized.

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Copyright 2007