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 CSWA Code of Ethics. I also agree with the purposes of the VSCSW to:

• Promote the highest standards of professional education and clinical social work practice;

• Promote clinical social work throughout the State through the formation of local chapters;

• Coordinate the activities of all the chapters;

• Educate the public of the specialized skills of clinical social workers;

• Collaborate with other health/mental health care professions on issues of common concern;

• Protect the rights of clinical social workers to practice; and

• Advocate for adequate and appropriate mental health services and insurance coverage at the state and national levels.

I also understand that current members of the Society are required to notify the President of the Society of any Disciplinary Order by the VA Board of Social Work within 30 days. The president at their discretion, may take no action, suspend, or terminate the LCSWs membership in the society.

AFFILIATE MEMBERSHIP FORM

(Retired from practice, or out-of-state resident)