Get Started.Please fill out form below to create an account Name * First Name Last Name NPI Number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Country (###) ### #### Fax (###) ### #### Email * Social Media Accounts Where did you attain your undergraduate degree from and what was your major? * Where did you attain your graduate degree from and what was your major? * Please list Degrees, Licenses and Certifications: * How long have you been practicing? * 1 - 3 years 4 - 6 years 7 - 12 years 12 and above Which state(s) are you licensed to practice in? * What is the address of your office? * Address 1 Address 2 City State/Province Zip/Postal Code Country Office Phone: * Country (###) ### #### Are you willing to work with: (Check all that apply) * Individual Couples Groups (If so, which group topics do you specialize in?) If you selected groups above, which group topics do you specialize in? Please identify which of the following you are willing to work with: (Check all that apply) * Male Female Other: Please List Please list other below: Do you have a preferred age of client that you like to work with: * Yes (If yes, please list) No If yes to above question (please list below) Do you prefer to counsel a particular sexual orientation? (Check all that apply) * No Heterosexual Gay Lesbian Bisexual Other: Please List Please list other below: Do you prefer to work with a certain population? (Check all that apply) * Single Married Separated Divorced Widowed Do you cater to a particular religion? * Yes (if yes, please list) No If yes to above questions (please list below) Do you work with clients who are impacted by the coronavirus outbreak? * Yes No Which issues do you specialize in? (check all that apply) * ADHD Addiction Alcohol Use Anger Management Antisocial Personality Anxiety Behavioral Issues Borderline Personality Child or Adolescent Chronic Illness Chronic Impulsivity Chronic Relapse Codependency Coping Skills Divorce Domestic Abuse Domestic Violence Drug Abuse Dual Diagnosis Emotional Disturbance Family Conflict Grief Infidelity Internet Addiction Life Coaching Marital and Premarital Narcissistic Personality Obsessive-Compulsive (OCD) Parenting Peer Relationships Racial Identity Relationship Issues School Issues Self Esteem Self-Harming Sexual Abuse Sexual Addiction Stress Suicidal Ideation Teen Violence Trauma and PTSD Video Game Addiction What specialty of mental health issues do you practice? * Dissociative Disorders Elderly Persons Disorders Impulse Control Disorders Mood Disorders Personality Disorders Psychosis Thinking Disorders Which Treatment Approaches Do You Specialize In? * Cognitive Behavioral (CBT) Dialectical (DBT) Family / Marital Family Systems Humanistic Internal Family Systems (IFS) Interpersonal Intervention Mindfulness-Based (MBCT) Motivational Interviewing Multicultural Other Evidence Based Practices Parent-Child Interaction (PCIT) Person-Centered Play Therapy Positive Psychology Psychoanalytic Psychodynamic Reality Therapy Relational Solution Focused Brief (SFBT) Strength-Based Structural Family Therapy Trauma Focused We will be in touch soon.
