Interim therapist | South Shore Coalition of Independent Therapists

Complete this form to access the PDF

To expedite your application process, we request that you provide some basic contact details. You can opt out of this if you'd like but it may prolong the application process.

Please enter your first and last name*

First Last

Please enter your first and last name for verification purposes.

License No. and State*

Please enter license number and state for verification purposes.

Phone

Please provide your phone number in case we need to contact you during the registration process.

Choose an email option*

I will type my email address below
I would like a new @sscit.org email address
I do not use email

Please make a choice from the options above, if you'd like to use your own email address, if you'd like to use an "@sscit.org" email address, or if you do not use email at at all. Based on your selection in this field, various options will be made available to you for completion of this form.

Enter your email address

Enter Email Confirm Email

Please enter your current email address. This is your easiest option- there is no additional setup required. Your account login details will be provided shortly.

Choose a new @SSCIT.org Email Address

Ok, you have chosen to set up a brand new email address which will be "your-mail"@sscit.org.

Replace "your-mail" with your selected address

We cannot promise that your chosen email will be available, but please enter an email address on the line above. If for some reason it is not available your submission will be halted, and you'll be asked to enter a different address.

This option requires some additional setup on your part. If you have never set up a new IMAP email address and are not comfortable with the procedure, this option may not be for you. However if you really do not want to use your own email address, despite our security measures, we can provide assistance for setting up your new email address.

You have chosen not to link an email address to your account. You will not have the option to edit your directory listing later or write blog articles if you proceed with this selection.

Annual Membership Dues

At this time we do not offer an online payment option, so member dues must be mailed the address listed above. Click yes to acknowledge that your payment must be recieved before your invitation code can be sent.

The fee for annual membership is $75.

A check for this amount must be mailed to SSCIT President Kenneth Freedman, at:
South Shore Coalition of Independent Therapists
41 Popple Bottom Road
Sandwich, MA 02563

You must agree to proceed:*

I Agree

Email

This field is for validation purposes and should be left unchanged.