Group Membership Form

Group Membership ACTBerlin

For a profile entry for a practice with more than one Therapist or Counsellor. Fees cost annualy €99 for the main person applying plus €40 for every other practitioner listed on the homepage connected to the profile. Bank details will be sent once your application has been accepted. You are responsible for the legal status of the services you offer in Germany and we assume that the information your provide is a reliable source that your qualifications and the qualifications of those working in your practice are in accordance with German law.
A psychology degree recognised in Germany or a Heilpraktiker für Psychotherapie status is required by each practitioner.
Please fill in all areas.
Name of the person making the application and paying for membership

First Name Last Name
Name of the Practice
Amount of Practitioners advertising on the website to be linked to this profile.
Area of Berlin where the practice is situated in.
Fluent Languages available to clients within the practice
Methods of payment acceptable from clients e.g. Private pay, Some health insurance, All Insurances Covered
What are the specialities available to clients within the practice?
E-mail
Telephone Number
Website URL
Practice Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address for the invoice if different from the above

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
By registering for ACT Berlin I agree to the Disclaimer and Registration Agreement that follows: DISCLAIMER   No guarantee whatsoever is made to anyone by ACT Berlin, its creators and organizers, David Barnes and Nadine D’Orsay, that the website and its directory will yield specific results or desired outcomes at anytime for its participants. ACT Berlin does not provide any individual sponsorship or promote any individual, group, practice, or organization. ACT Berlin takes no responsibility for the information provided by each registrant. The functioning ACT Berlin is solely to provide open source information concerning therapeutic and counseling resources in Berlin, Germany. As a website, information will not be restricted to residents of Berlin, and will be placed online and accessible internationally. REGISTRATION AGREEMENT You are registering to be listed in the therapist directory on the website www.actberlin.info. Terms of Agreement 1. Notification of Copyright, Trademark and other Proprietary Information The organization and its creators and organizer own all and any copyright, trademark and other intellectual proprietary rights to all the information presented on the website www.actberlin.info, including but not limited to, information, trademarks, content, documentation, texts, articles, illustrations, graphics, audio and video presentations, processes, exercises, tools, icons, updates and all other training related materials. You may not modify, reproduce, display, distribute, post, transmit, record, tape, film, publish, create derivative works from, transfer, sell or perform any of the related information and materials, in whole, in part or in any other manner by any means without the prior expressed written permission of ACT Berlin. 2. Registration Fee The registration fee for ACT Berlin covers the cost of core functions that benefit all members. Annual registration dues are currently €99,00 per year for the main person applying plus €40 for every other practitioner listed on the homepage connected to the profile. New registrants are requested to pay within 7 days after online registration. ACT Berlin retains the right to reject applications without feedback. I certify that I have read the registration and disclaimer statements. I hereby consent to and agree to be bound by such restrictions and disclaimer and the payment of the according registration fee indicates that I have accepted these terms. I understand that my membership is limited to 12 months. I understand that all the information that I have provided is true, and that ACT Berlin takes no responsibility for the information provided.
How we use your information

We store data related to your email address, telephone number work or (where it is the same as your work) home address. This information is required for your invoice and our accounts. We don’t share any information unless you have submitted it for inclusion on your online profile. Your name and address is visible to any relevant financial services dealing with actberlin.info tax submissions. This is included on our invoices.

With your permission, we will contact you occasionally via email with information related to actberlin.info

This information will include necessary changes to our website or to your profile. We will also contact you via email to inform you that your membership agreement is approaching an end. This gives you the possibility to renew membership.

Permission to contact actberlin members is limited to Nadine D’Orsay and David Barnes, actberlin founder members only. Circular, group emails to actberlin members from other members are no longer legal.

When submitting your information for inclusion in your online profile at actberlin.info this information is accessible to any visitor to actberlin.info, which enables potential clients to contact you.

Your information is stored securely and is deleted if your membership runs out or if you withdraw your membership.

You may withdraw consent of contact at any time by notifying us that you wish us to delete your data, upon which we will delete any data we have stored.

When someone visits www.actberlin.info we use a third party service, Google Analytics, to collect standard internet log information and details of visitor behaviour patterns. We do this to find out things such as the number of visitors to the various parts of the site. This information is only processed in a way which does not identify anyone.
Please read the information regarding Privacy and Data Storage above How we use your information *

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Group Membership ACTBerlin