|
CONTACT & QUALIFICATION/CREDENTIAL
INFORMATION TO BE POSTED ON THE WEB SITE DIRECTORY PAGE FOR DISPLAY
TO ALL SITE VISITORS: |
|
YOUR NAME/TITLE (e.g., Dr.
Mary G. Brown; John Wells, LCSW; Lucinda Miles, MD, etc.)-- as
you wish it to appear in your Directory listing:
|
|
OFFICE AT WHICH CLINICAL HOURS
ARE HELD:
(Name of Agency,
if applicable: )
Street Address:
City/Town:
State/Province:
Country:
Zip/Postal Code:
|
TELEPHONE
NUMBER(S) AT WHICH POTENTIAL CLIENTS MAY REACH YOU:
|
| Name
and URL of any web site you would like to offer a link to, as
part of your Directory listing:(not required) |
| E-mail
contact: We do not advise that you post an e-mail address in
the Directory listing, but if you feel you would like to do so,
please include it in the box in this row--but be aware that
this Directory is open to the public, so if you post an e-mail
address, anyone can use it (i..e, not just potential clients!).
(NOT REQUIRED, NOT ADVISED) |
| EDUCATION,
TRAINING, SPECIALTIES, CREDENTIALS, QUALIFICATIONS: for inclusion in your listing in the
Online Directory: complete separate items below. |
RELEVANT
PROFESSIONAL ACADEMIC DEGREES:
Please list name or initials of the academic degree, the field
of study if this is not obvious from the name of the degree,
and the institution granting the degree. Please also include
the location of the institution.
(E.g.:
MD, Columbia Univ., NYC, New York
Master of Social Work, SF State Univ., San Francisco
DPhil, Clinical Psychology, Sorbonne, Paris, France):
|
| SPECIALIZATIONS:
(e.g., Children 5-10 yrs., play therapy; Children, Adolescents,
and Adults, longterm & brief psychotherapy, Self- Psychological
orientation; Family Therapy; Substance Abuse, teen; etc.): |
|
LICENSURES/CERTIFICATIONS -
Please include the name of the State or national body that grants
the license. (Enter more than one in a box if you run out of
space.)
Internet address (URL) at which
your licensure/certification can be verified: NB--If you're not
sure where to look online for license verification for professionals,
start with your State web site and search on "professional
regulation" or "licensure" or "professions,"
or call your State government information line and ask where
you can find this info online.
|
| NUMBER
OF YEARS IN PRACTICE (MENTAL HEALTH DISCIPLINE): |
PROFESSIONAL
ORGANIZATIONS/MEMBERSHIPS: (7 boxes are provided, but feel free
to enter more than one organization/membership activity in a
box if you run out of room.)
|
| ADVANCED TRAINING
OR WORKSHOPS COMPLETED OR OTHER ACHIEVEMENTS: |