Resource Provider Profile

Name : Credentials:
Organization:
What year did you start practicing? Email :
Phone: Fax:
Address: City:         State:         Zip:
Website:
Type of Service EAP Extended Care Halfway House/Sober Living Inpatient Hospital Intensive Workshop Interventionist Intensive Outpatient Program (IOP) Outpatient Partial Hospitalization Residential Other	Education Psychiatrist Other Physician Psychologist Doctorate, Non-Psychologist Master's Bachelor's Certification Nursing RD (Registered Dietician/Nutritionist) Clergy Legal Non-Clinical Other
Specialty Adolescent Adult (18+) Adult Child of Alcoholic (ACOA) Anger Management Anxiety ADHD Axis II Diagnosis CD/Alcoholism Children Codependency Compulsive Gambling/Spending Dissociative ID Disorder Divorce Domestic Violence Dual Diagnoses Eating Disorders Equine Gay/Lesbian/Bisexual/Transgender Grief & Loss Internet Addiction Medication Management Men's Issues Mood Disorders OCD Pain Management Sexual Addiction Sexual Offenders Smoking Cessation Suboxone Management Trauma Women's Issues Other	Modality 12-Step Approach Acupuncture Art/Music/Dance Therapy Biofeedback Cognitive-Behavioral Therapy (CBT) Couple's Counseling Dialectical Behavior Therapy (DBT) EMDR Experiential Therapy Family Therapy Guided Imagery Hypnotherapy Imago Individual Therapy Massage Meditation/Relaxation Neurotherapy Psychodrama Reiki Somatic Experiencing ® Vocational Counseling Group Therapy (Specify): Other:
Fee Range for Services Private Pay: % of practice Insurance: % of practice Medicare	Do you refer to Inpatient Treatment? Yes No
Notes:

Self Evaluation

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- Select Evaluation - Alcoholism Anxiety Compulsive Gambling Depression Family Drinking Sexual Addiction

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