Application for Membership to Christian Referral Service

Membership to our referral service is open to: Individuals who have earned their degree as a: Psychiatrists (M.D., D.O), Psychologists (PhD or PsyD), Social Workers (MSW, LCSW), Licensed Professional Counsellor (LPC), or Licensed Marriage and Family Therapists (LMFT).

All income generated by this service will be donated to Hope for the Suffering, a Christian ministry reaching out to suffering children around the world. 100% of all monies donated to Hope for the Suffering go to the needy.

Please select the type of Listing:
Missionary Listing if you have a ministry wherein you treat patients without charge, your "standard" listing is free
Standard Listing includes name, specialty, address, phone, fax & e-mail address donation of $120.00 per year (see sample)
Enhanced Listing includes above information, plus narrative and color photo donation of $180.00 a year (
see sample)

Please provide us with information to enhance your listing:
( You may enter up to 700 characters. )

characters left
For enhanced listings, please send a current photo to: Christ Centered Graphics & Web Design, P.O. Box 152146, Cape Coral, FL 33915-2146. Photo should be in color, no larger than 5 x 7 and no smaller than 3 x 5 inches. Alternatively, you may e-mail a picture in either .jpg, .gif or .bmp formats to Christ Centered Graphics at ccg@giversministry.org . 

 

 

Please provide us with the following information: (* indicates a required field)

*First Name

*Last Name
*Street Address
 
*City
*State
*Zip/Postal Code
*Area Code
*Telephone
Fax
 *E-mail Address
 *Date of Birth
(MM/DD/YYYY)

*Degree (M.D, N.D., etc.)

*Medical School

*Year of Graduation
(YYYY)

What information do
you NOT want included
in your listing
(i.e., address, telephone)
Representations
  • If you have been convicted of fraud or a felony within the last 5 years, check here
  • If any action, in any jurisdiction regarding your license has been taken within the last 5 years (this includes any action regarding any limitation, probation, revocation, and any other sanction or conditions upon your license), check here
  • If you have been the subject of any disciplinary action by any hospital staff or medical society within the last 5 years, check here
  • If you have ever been a party to a malpractice lawsuit? check here
  • Do you carry malpractice insurance? Yes No
  • Do we have your permission to check your records with the Physician Data Bank and also to check your references? Yes No

Payment

Please mail your Check or Money order payable to Hope for the Suffering, 303 Woodrow Wilson Drive, Valdosta, GA 31602. We will process your application within 48 hours after your payment is received.

 
   
 

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