Date:
Name:
Gender:
Name of Practice:
Mailing Address:
Physical Address:
Work Phone:
-
E-mail:
Website:
Certification/License:
Certification State:
Date License Received:
I offer the following low-income options:
I would like to be added to your email list in regard to HAVEN:
Are you currently accepting new clients?
Have you ever had a judgement of malpractice/misconduct by the Board of Examiners or license revocation? (If yes, please specify on a separate sheet of paper.)
Is your practice wheelchair accesible?
If no, are you willing to meet clients at another location?
Do you offer services in languages other than English?
If yes, please list which languages you provide services in:
Do you work with offenders of sexual assault or domestic violence?
Does your practice accept any of the following insurance options? (Check all that apply)
If you offer pro-bono or sliding scale services, please specify your criteria:
Do you currently work with sexual assault and domestic violence survivors?
If yes, how long have you been working with clients in regard to these issues?
Do you provide Trauma Informed Services? Please explain:
Please indicate the age range with which you have expertise: (Check all that apply)
Please indicate with which client populations you have significant expertise: (Check all that apply)
Please list any support or therapeutic groups that you offer:
I work with: (Check all that apply)
Please indicate your areas of specialization. (Check all that apply)
If 'Other' specialization, please explain:
Which therapeutic models do you work with? (Check all that apply)
Other therapeutic services you offer:

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