Mental Health & Wellness Resource Guide

Mental Health & Wellness Resource Guide
Name*

First NameLast Name
Professional Email*
example@example.com
Professional Phone Number*
Please enter a valid phone number.
Are you currently accepting new clients?*

YesNo
If no, do you know when you will be accepting new clients?
Website
Are you currently a licensed clinician?*

YesNo, I am currently a pre-licensed clinician
If yes, please state your correct credentials
If no, please state the first and last name of your Supervisor
Are you currently an Approved Supervisor?*

YesNo
Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of session currently serviced*

HybridIn-person onlyTelehealth onlyOther
Specialties and Expertise*
Would you be interested in speaking engagements about your expertise?*

YesNo
Fees
Individual Sessions *
Couples Sessions
Family Sessions
Do you accept insurance?*

YesNo
If yes, please select the insurances you currently accept.

AetnaBeaconBlue Cross Blue ShieldCapitalCignaEmpireFederalFirst HealthGEHAHealth AmerivanHighmarkIndependenceHorizonKeystoneMagellanOptumPenn Behavioral HealthPersonal ChoiceTricareUs Family Health PlanUnited Behavioral Health CareVA Community CareWellmarkOther
Do you offer a sliding scale option?*

YesNo
Select the payment options you accept.*

Credit CardMobile Payment Services ( Cash App, PayPal, Venmo, etc.)CashDigital PaymentOther
Client Focus
Ethnicity*

BlackWhiteHispanicAsianOther
Religion*

ChristianityIslamJudiasmNon DenominationalNoneOther
Age*

ToddlerChildrenPreteenAdolescentAdultsSeniors
Treatment Approach
Please select the type of therapy you provide.

CBTDBTPsychodynamic TherapyInterpersonal TherapyHumanisticBehavioral TherapyCognitive Processing TherapyEFTGroup TherapyPsychoanalysisArt TherapyDance TherapyChristian CounselingExposure TherapyAversion TherapyAdlerian TherapyAttachment therapyCouples TherapyMindfullnessACTOther
Are you interested in receiving clients referred by the courts?*

YesNoOther
Please select if you currently serviced the following areas:*

Bucks CountyChester CountyDelaware CountyMontgomery CountyPhiladelphia
Any additional comments or questions you have. *
Should be Empty:

Mental Health & Wellness Resource Guide

Fees

Client Focus

Treatment Approach