Membership Application - Connecticut Council for Non-Adversarial Divorce

Your Information

First Name

Middle Name

Last Name

Please indicate the membership level you are applying for

Individual Membership

Whole Group Membership (must provide Whole Group information)

Newly Trained Professional Membership

Retired Membership

Student Membership

Provisional Membership

Nonprofit Organization Membership

Application Type

Renewal

New Application

Is all your member and contact information unchanged?

Correct. No changes.

I have updated information to submit.

Member information

Firm Name (if applicable)

Office Address

City

State/Province

Zip/Postal

Office Phone

Cell Phone (not for publication)

Home Phone (not for publication)

Email*

Website

Profession (including designations, if any)

Are you a member of one or more collaborative practice group(s)?

Yes

No

If you are applying for Whole Group membership, you must check "yes".

Collaborative Practice Group

Collaborative Practice Group Information

Name of your Collaborative Practice Group(s)

Which, if any, are Whole Groups?

Name, phone & email of Whole Group leader(s)

New Applicant Information

New Applicants

Please affirm that you meet the CCND membership criteria for Collaborative Professionals and/or Mediators by checking the appropriate box(es) below. The criteria are found here, on the CCND website.

I affirm that I meet the membership criteria of CCND as a:

Collaborative Professional

Mediator

Check each that applies.

Please Indicate Trainings Completed (Select all that apply)

40 Hour Basic Family Mediation Training

Introduction to Interdisciplinary Collaborative Training

Indicate 40 Hour Basic Mediation training dates and trainer name(s)

Please list dates of training and names of trainer(s).

Indicate Collaborative Divorce training dates and trainer name(s)