Thank you for your interest in the Therapeutic Resource Directory at ParentingAdolescents.com (and/or the Camp Directory). This educational, non-commercial site accepts listings only from practitioners and agencies or organizations that in our opinion offer exceptional clinical expertise and resources or worthwhile camp experiences.

The Therapeutic Resource Directory posted at this site is meant to serve people who visit the site in search of help in understanding/managing their adolescent or pre-adolescent child or, for the adolescent visitor, help in understanding self, parents, and society. AGENCIES/ORGANIZATIONS LISTED IN THIS DIRECTORY MUST BE QUALIFIED TO SERVE ADOLESCENTS AND PRE-ADOLESCENTS, AND/OR THEIR FAMILIES.

Please read all of the information in this table before beginning to complete the two-part Application! Thanks!

We will use the information in Part I below as the source of your online listing in the Therapeutic Resource Directory.

The information in Part II of the Application will be used by administrators at the web site and will not be posted online. Please include an e-mail address or fax # in part II.

*NB: If your agency/organization wishes to be listed at more than one location, with full specification of the services/staff available at each, please use a separate application for each location. Subsidiary sites of the same organization will be included in the Directory for the reduced fee of $80.00 US (after the main site is listed at full fee of $150 US). [Camps are allowed to apply for a six-month listing at $75 US.]

If your agency/organization has offices at more than one location, but does *not* wish a separate listing at each, please include in Part I the address/phone number information for your “main” office or location, and you may include other office locations and one phone number for each, under “other offices/locations” at the end of this Part. We will list the name(s), location(s) and phone number(s) [only] of your other office(s)/location(s) in your main listing.

When you have completed both parts, please check a box to indicate your means of payment of the appropriate fees, as designated at the end of the Application. (To use Visa or MasterCharge, leave the name of the card holder, the type of card, the card number, and the expiration date on confidential voicemail at 847-926-8328.)

Your agency’s or organization’s listing will be secured for one calendar year from the date of first posting. You will be notified by e-mail of the date on which the listing is first posted.

You must complete all fields except those marked with a blue "pound" sign (#); these marked fields are required only under certain circumstances, which will be explained as you progress through the application. Fields will expand to accommodate your information. When you have finished, click on the "Submit App" button at the end of the Application. (Note that you can proceed from one field to the next by using the "TAB" on your keyboard, and navigate backwards through the fields by using "Shift" and " TAB" together.)

If you would prefer a hard copy of this app., send us e-mail, and we will forward. Click below to...

Name of agency/organization, as you wish it to appear at the top of listing:

Complete address of the agency/organization, to be displayed for potential clients’ reference:
[Camps are allowed to list a website address, if that is the preferred mode of contact for potential clients.]

Phone numbers at which potential clients may contact the agency/organization at the location listed above (include the names or position titles of persons prospective clients should ask for, if any):

Regular (non-emergency) phone:

Contact:
#

2nd Phone:
#
Contact:
#

SPECIFY AN EMERGENCY NUMBER IF YOU HAVE ONE:

Emergency Phone
#
Ask for
#
More information re emergencies:
Additional ER info:#

Director, President, or other Head of your agency/organization:

Name:

Title:

Credentials/Degrees (e.g., PhD, LCSW, PsyD, MBA, MA):

Mission or Purpose of your agency/organization: (Not more than 50 words)

Mission:

Populations served by your agency/organization: (e.g., age groups, types of need or condition, geographical restrictions or catchment areas if any, and/or other qualifiers):

Populations we serve:

What are the sources of income that support your agency/organization? (E.g., United Way, client fees, township contributions, private donors, grants, foundations, corporate contributions, arrangements with health benefit management organizations, etc.)

#Do you offer specific programs?
If so, you may wish to describe each in the table below.

[If you do *not* wish to detail your specific programs, click here to be taken to next relevant section.]

(The information in this table is required IF you have specific programs for clients that you wish to include in your listing. To add additional programs, click “more” at end of table. Then, be sure to come back and fill out the rest of this section, using the link, "Complete rest of section.")

What types of payment for services to clients do you accept? (Insurance? Specific carriers? Direct pay from clients? Credit card? Other?)

Is there a sliding fee scale, based on client income, to adjust fees? (Check one box):
Yes No
Is there some provision for adjusting client fees other than sliding fee scale? Check one box:
Yes No

IN THIS SECTION, please tell us about attributes of your agency that would recommend it to potential clients:

1. Is there COA, JCAHO, or other accreditation by recognized Health Organizations? Check one box:
Yes No
If Yes, please specify:
#

2. Please tell us about anything that leads you to believe that your agency/organization is recognized and esteemed by clients, the community, and/or other health care providers or organizations like your own:
Why our agency is esteemed:

3. For how long (in years) has your agency/organization been serving people’s mental health needs or camp needs in your community or catchment area?

4. Please tell us about any grants, awards, or other specific honors or recognitions your organization may have received, or any achievements you may wish mentioned:

Grants, awards, etc:#

5. Please list anything else you would like people to know about your agency/organization:

#

Do you wish your listing(s) to include a link to your web site?
Yes No
If yes, write the NAME of the web site here:
#
Write the URL of the web site here:
#
(The two fields immediately above, web site name and URL, are obviously required only IF you have a web site to which you wish a link inserted in your listing.)

Do you wish to upload your own graphics to be added to your listing at www.parentingadolescents.com? (An additional fee of $25 per graphic is charged for downloading and inserting your graphics.)
Yes, we have original graphics to be inserted
No, please work with us on graphics for our listing

Add program descriptions here:

Name of Program	Target Population	Program Mission or Therapeutic Intent	Program Cost to Client
(program name)	(pop served)	(mission)	(cost)
(program name)	(pop served)	(mission)	(cost)
(program name)	(pop served)	(mission)	(cost)
(program name)	(pop served)	(mission)	(cost)

If you still need more space to describe programs, use this box:

ADDITIONAL PROGRAM INFO:

Your clinical/therapeutic or direct child-contact staff:
Please describe, using the table below, the average qualifications of your staff, by job title.

The staff will *not* be listed by name in your Online listing--unless you so request.

In the last, "Other" column, you may add specialties, advanced training, achievements, languages, other qualifications or attributes that may prepare them to deal with specific populations (e.g., are there staff who identify themselves as of alternative sexual orientation, are there African-American, Asian, Hispanic or staff of other racial/ethnic/national heritages, are there staff who speak Spanish or another language other than English, are all staff of a certain religion, etc.). (Note: completion of fields in this column is suggested but not required.)

Are all of your staff insured against malpractice or malfeasance?
Yes No

Either the first two fields, or the third field, must be completed in this section if you are a mental health service organization:
Specify malpractice insurance company and date insurance expires, if one company insures all staff:
1. Malpractice insurance provided by:
#
2. Expires:
#

3. If each practitioner carries her/his own malpractice insurance, specify how you determine whether malpractice insurance is in effect:
#

Please use the table below to describe the general qualifications of the staff who supervise your clinical (if you are a mental health services organization) or child-contact (if yours is a camp) staff, by the job title supervised.

A. If yours is a mental-health services organization:
Do you schedule at least 45 minutes to one hour of one-to-one clinical supervision weekly for each clinical/therapeutic staff person? Check one:
Yes No

B. If the answer to “A” is “No”: What is the supervision schedule for your clinical staff, and what is the nature and duration of each supervision session? (E.g., Group supervision--1 supervisor to 4 staff, 2 hours weekly, rotating case presentation; one-to-one 50-minute supervision monthly, process recordings/tapes required) This field is required if answer to A is No.

Alternative supv arrangement:

Describe continuing education/inservice made available to your staff by your agency/organization and/or your continuing education or inservice requirements of staff (this must be answered only by clinical/mental health services organizations).

Inservice/continuing ed:

Administrative contact info:

Agency location/site:

Contact name:

Title:

E-mail address of this person:

Postal mail address of this person:

Telephone number(s) of this person:

Fax number(s) for this person:
#

Contacts regarding directory listing design issues:

Agency location/site:

Design contact name:(If design contact person is same as administrative contact person, enter "Same" in this field.)

The following 5 fields are required to be completed if you did *not* enter "Same" in the previous field:

Contact person title:
#
E-mail address of design contact:
#
Postal mail address of design contact:
#
Telephone number(s) for design contact:
#
Fax number(s) for design contact:
#

For each agency site to be listed in the Directory, please include the above contact information. You may list the additional sites and the related contact information in this box:

OTHER SITES AND CONTACT INFORMATION FOR EACH:

After you complete this section, you will be ready to review your information and then submit your application online by clicking on "Submit Application."

Fees:

$150 US for one listing for one organization for one calendar year (for additional offices, addresses and phone numbers only may be included in this listing at no extra cost)

$80 US per subsidiary-site listing for organization already included at regular fee

$75 US for a camp listing for six months

Enter total payment (in US dollars):

Method of payment: please check one -

check or money order to Parenting Adolescents, sent by postal mail to address below
Visa or MasterCard (no other credit cards are accepted)--number, name of cardholder, and expiration date may be left on confidential voicemail at 847-926-8328

Check or money order should be made to Parenting Adolescents and sent to:

Parenting Adolescents
c/o Jean Walbridge, LCSW
1803 St John's Ave.
Highland Park, IL 60035
USA

When you are ready, click on "Submit Application" below. Your application is not complete until you have clicked "Submit Application."

After you click on "Submit," you will be taken to a screen that will show the information you have submitted. (You may wish to print a copy of this screen.) If you find, in reviewing that screen, that you have made a mistake or wish to change anything, just hit the back button or arrow on your browser, and you can navigate to the missing or incorrect fields and correct the info. Once corrections have been made, click "Submit" again.

After receiving and reviewing your Application and fee, we will notify you of acceptance to the Directory. The next step will be to work with you on the appearance and content of your listing. We don't start your calendar year until your listing, as approved by you, is actually posted to the Internet at www.ParentingAdolescents.com .

But first: You may wish to review your information before you submit. Here is a link to the beginning of the application: Beginning

Thank you for your application. We hope to be notifying you of acceptance soon! Ready?--now, click below:

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Updated 8/5/2001. Copyright © Karen Martin 10/98, all rights reserved.