Rendering Provider *

First Name

Last Name

Multi-cultural Expertise *

African-American

Hispanic

Alaskan Native

Indian

Arabic

Irish

Armenian

Italian

Asian

Native American

Brazilian

Pacific Islander

Cape Verdean

Portuguese

Caribbean

Russian

Haitian

Forms of Payment Accepted *

BCBS

Aetna

United Healthcare

Humana

Cigna

Tricare/Humana Military

Magellan

EAP

Self Pay

Other

Service Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Accessibility

Please indicate access to your organization or office.

Access by Public Transportation

Access by Wheelchair

Emergency Appointments

Evening Office Hours

Home Visits

Mobile Services (Van, etc.)

Online Therapy (email, live chat, video)

Secure Video Counseling (Regroup)

Telephone Counseling

Video Counseling (Skype, etc.)

Weekend Office Hours

Office Number *

(###)

###

####

Fax Number

(###)

###

####

Ages and Populations Served *

Expertise with Age Groups (please check all that apply)

Preschool (Under 6)

Young Adults (18-25)

Children (6-12)

Adults (26-59)

Adolescents (13-17)

Seniors (60+)

Religious Expertise *

Buddhist

Christian

Hindu

Jewish

LDS/Mormon

Muslim

Pagan

Other

Languages *

Please indicate any languages, other than English, in which you are fluent.

French

German

Greek

Gujarati

Haitian

Hawaiian

Hebrew

Hindi

Hopi

Hungarian

Igbo

Ilongo (Ilonggo)

Indian

Italian

Japanese

Kannada

Khmer

Korean

Lakota

Laotian/Lao

Lebanese

Lithuanian

Marathi

Norwegian

Persian

Polish

Portuguese

Punjabi

Romanian

Russian

Serbian

Spanish

Swahili

Swedish

Tagalog

Taiwanese

Tamil

Telugu

Thai

Turkish

Ukranian

Urdu

Vietnamese

None

Mental Health Specialities *

Check all that apply.

Academic Accommodations

Addictions/Other (gambling, sex, etc.)

Addictions/Substance

Adoption/Foster Care

Aging

Anger Management

Anxiety/Panic Disorders

Asperger's Syndrome

Attachment Disorders

Attention Deficit (Hyperactivity) Disorder

Autism Spectrum

Behavioral Problems

Bipolar Disorders

Body Dysmorphic Disorder

Career/Employment Concerns

Child Abuse and Neglect

Couple or Marital Issues

Dementia

Depression

Developmental Disability

Dissociative Disorders

Domestic Violence

Dual Diagnosis

Eating Disorders

Education/Personal Development

Elder Abuse

Factitious Disorders (Munchausen Syndrome)

Family Issues

Firesetting

Forensic

Gender Identity

Grief/Loss

Immigration/Newcomer

Infant Mental Health

Infertility

Interpersonal Relationships

Learning Disabilities

Life Transitions

Medication Management

Memory Problems

Men's Issues

Multicultural Issues

Neurological

Neuropsychological Testing

Obsessive/Compulsive Disorder

Pain Management

Parenting Issues

Personality Disorders

Phobias

Physical Illness/Impairment

Postpartum Depression

Pregnancy/Childbirth

Psychoses/Major Mental Illness

Psychosomatic

Runaways

Selective Mutism

Self Abuse

Sensory Processing Disorder

Sexual Abuse/Rape

Sexual Disorders

Sexual Orientation

Sexuality Issues

Sleep Disorders

Spiritual/Religious Concerns

Stress

Suicidal Thoughts

Tourette's Disorder

Trauma/PTSD

Traumatic Brain Injury