Mental Health & Wellness Resource Guide
Name
*
First Name
Last Name
Professional Email
*
example@example.com
Professional Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently accepting new clients?
*
Yes
No
If no, do you know when you will be accepting new clients?
Website
Are you currently a licensed clinician?
*
Yes
No, 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?
*
Yes
No
Office Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of session currently serviced
*
Hybrid
In-person only
Telehealth only
Other
Specialties and Expertise
*
Would you be interested in speaking engagements about your expertise?
*
Yes
No
Fees
Individual Sessions
*
Couples Sessions
Family Sessions
Do you accept insurance?
*
Yes
No
If yes, please select the insurances you currently accept.
Aetna
Beacon
Blue Cross Blue Shield
Capital
Cigna
Empire
Federal
First Health
GEHA
Health Amerivan
Highmark
Independence
Horizon
Keystone
Magellan
Optum
Penn Behavioral Health
Personal Choice
Tricare
Us Family Health Plan
United Behavioral Health Care
VA Community Care
Wellmark
Other
Do you offer a sliding scale option?
*
Yes
No
Select the payment options you accept.
*
Credit Card
Mobile Payment Services ( Cash App, PayPal, Venmo, etc.)
Cash
Digital Payment
Other
Client Focus
Ethnicity
*
Black
White
Hispanic
Asian
Other
Religion
*
Christianity
Islam
Judiasm
Non Denominational
None
Other
Age
*
Toddler
Children
Preteen
Adolescent
Adults
Seniors
Treatment Approach
Please select the type of therapy you provide.
CBT
DBT
Psychodynamic Therapy
Interpersonal Therapy
Humanistic
Behavioral Therapy
Cognitive Processing Therapy
EFT
Group Therapy
Psychoanalysis
Art Therapy
Dance Therapy
Christian Counseling
Exposure Therapy
Aversion Therapy
Adlerian Therapy
Attachment therapy
Couples Therapy
Mindfullness
ACT
Other
Are you interested in receiving clients referred by the courts?
*
Yes
No
Other
Please select if you currently serviced the following areas:
*
Bucks County
Chester County
Delaware County
Montgomery County
Philadelphia
Any additional comments or questions you have.
*
Submit
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