Credentials:
Agency Name (or Private Practice):
Street Address:
City & ZIP:
Mailing Address: (If different from street address)
Phone:
Email:
Web site:
Office Hours:
How would you describe your profession? (Please check all that apply)
Other:
Please list your DOH license(s) and/or other qualifying certification:
Where did you get your training and how long have you been in practice?
What age and type of clients do you serve?
Please check all your specialities:
What sort of evaluation and treatment services do you offer? Please check all that apply:
Is your practice open to new patients? If so how long is the wait?
Do you speak a language other than English? If so, which language(s)
Do you offer a sliding fee scale? What are your fees?
Please check all that you accept. You may comment in the "Other" text box.
