Private Practice Refferal Questionnaire
Name
*
First Name
Last Name
Pronouns
Do you currently volunteer at OUR HOUSE Grief Support Center as a grief group facilitator? (The OH Volunteer Agreement requirest current group leaders to agree that they will not accept group members or their family members into their private practice or business).
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Website
Zip Code (where you practice)
License or Title
If not licensed, please provide your supervisor's name, license #, title)
Is the license current?
Yes
No
Are you currently accepting new clients?
Yes
No
Are your services:
Telehealth
In Person
Hybrid (both telehealth & in person)
Telehealth moving to in-person
Other
What forms of payment do you accept?
Insurance
Out of Pocket
Sliding Scale
Type option 4
Other
What are your fees/fee structure?
If you accept insurance, please list what is accepted:
Populations served? Example: Adults, children, seniors, specific age ranges.
Are there limitations to your practice that you want us to know (e.g., will not take certain insurances, does not work with adults, etc.)
Optional: On occasion, OUR HOUSE receives requests from callers for referrals to therapists who are members of specific communities (i.e. requests for therapists of a specific cultural or ethnic background, gender, age, ability, sexual orientation, or religion). Which communities, if any, would you want us to identify you with when providing referrals to people who request it?
In detail, please describe any experience you have relating to grief and death in a clinical setting
What is your clinical approach/philosophy to grief as it relates to the death of a person in your work?
Are there any additional specialities, trainings, or certifications you would like to share?
Is there any other information you would like to add or share with us?
Submit
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