Provider Vetting Questionnaire v1.0

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Phone Number* This field is required.Best professional number to reach you at

Area Code

Phone Number

Gender* This field is required.Demographic information collected for the purposes of client preference when referring

Male

Female

Non-binary

Transgender man

Transgender woman

Prefer not to say

Other

How do you identify your race or ethnicity?* This field is required.Demographic information collected for the purposes of client preference when referring

Asian

Black or African American

Hispanic or Latino/a

Middle Eastern or North African

Native American or Alaska Native

Native Hawaiian or Pacific Islander

White

Prefer not to say

Other

What is your religious or spiritual affiliation?* This field is required.Demographic information collected for the purposes of client preference when referring

Agnostic

Atheist

Buddhist

Christian

Hindu

Jewish

Muslim

Spiritual but not religious

No religious affiliation

Prefer not to say

Other

How do you describe your sexual orientation?* This field is required.Demographic information collected for the purposes of client preference when referring

Asexual

Bisexual

Gay

Heterosexual (Straight)

Lesbian

Pansexual

Queer

Prefer not to say

Other

Languages you provide therapy in other than English

Credential of licensure* This field is required.Select all that apply

Psy.D.

Ph.D.

LCSW

LMFT

LCPC

LPC

Other

Number of years practicing independently* This field is required.

0-2 years

3-5 years

6-10 years

11-20 years

20+ years

Primary state license* This field is required.

If psychologist, are you a member of PSYPACT?

If counselor, are you a member of the Counseling Compact?

Other state licensesOnly select if you are directly licensed with the state (If subject to PSYPACT, please leave blank)

Have you ever had any disciplinary actions, sanctions, or restrictions placed on your professional license in any state or jurisdiction?* This field is required.

Yes

Other

Work experienceProvide company, setting, title(s), years employed (e.g., Rogers Behavioral Health, IOP/PHP, Intake Clinician, 2015-2020)

EducationInclude school, degree and year graduated (e.g., U Chicago, MSW, 2005)

Practice name* This field is required.If you practice independently, just include your name

Practice website* This field is required.Please include your practice website or your profile on a site like Psychology Today or similar

Are you accepting new clients?* This field is required.We will collect availability and scheduling information in the future

YESNO

What types of sessions do you offer?* This field is required.Select all that apply

In Person

Virtual

Hybrid/Both

If you offer in person, what is the primary location?City, State

Self-pay rate per hour?* This field is required.

Primary areas of specialization or core competencies* This field is required.

ADHD

Anger Management

Anxiety Disorders - Agoraphobia

Anxiety Disorders - Generalized Anxiety Disorder

Anxiety Disorders - Panic Disorder

Anxiety Disorders - Social Anxiety/Social Phobia

Autism Spectrum

Bipolar Disorders

Body Image

Body Dysmorphia

Career Counseling

Chronic Illness

Chronic Pain

Codependency

Depression/Depressive Disorders

Dissociation/Dissociative Disorders

Divorce

Domestic Abuse

Dual Diagnosis

Eating Disorders - Anorexia

Eating Disorders - ARFID

Eating Disorders - Binge Eating

Eating Disorders - Bulimia

Eating Disorders - Rumination Disorder

Family Conflict

Gambling, Internet/Social Media Use

Gender Dysphoria

Grief

Illness Anxiety

Infertility

Infidelity

Insomnia

Learning Disorders

Life Transitions

Loneliness

Marital and Premarital

Men's Issues

Nightmares

Obsessive-Compulsive Disorder (OCD)

OCD Related - Hair Pulling

OCD Related - Hoarding

OCD Related - Skin Picking

Paraphilias

Parenting

Personality Disorders

Personality Disorders - Antisocial Personality

Personality Disorders - Avoidant Personality

Personality Disorders - Borderline Personality

Personality Disorders - Dependent Personality

Personality Disorders - Histrionic Personality

Personality Disorders - Narcissistic Personality

Personality Disorders - Obsessive-Compulsive Personality

Personality Disorders - Paranoid Personality

Personality Disorders - Schizoid Personality

Personality Disorders - Schizotypal Personality

Racial Identity Development

Relationship Issues

Self Esteem

Self Harming

Sexual Abuse

Sexual Addiction

Sexual Dysfunctions

Sexual Identity

Sports Performance

Stress

Substance Use/Alcohol and Other Drugs (Abstinence)

Substance Use/Alcohol and Other Drugs (Harm Reduction)

Suicidality

Trauma and PTSD

Traumatic Brain Injury

What specific populations do you have experience working with?* This field is required.

Children

Adolescents / Teenagers

Young adults

Athletes

Adults

Executives/Business Professionals

First Responders

Elders (65+)

LGBTQ+

Black, Indigenous, and People of Color (BIPOC)

Migrants

Men

Women

Non-Binary / Gender Nonconforming

People with disabilities

Veterans

Other

What therapies and treatments do you use?* This field is required.Select up to 7

Acceptance and Commitment Therapy (ACT)

Adlerian

Art/Expressive Arts

Attachment-Based

Biofeedback

Coaching

Cognitive Behavioral (CBT)

Cognitive Processing (CPT)

Compassion Focused (CFT)

Christian Counseling

Dialectical (DBT)

Eye Movement Desensitization and Reprocessing (EMDR)

Emotion Focused (EFT)

Existential

Exposure & Response Prevention (ERP)

Family Systems

Feminist

Gestalt

Gottman Method

Imago

Internal Family Systems (IFS)

Interpersonal Process

Interpersonal Therapy (IPT)

Jungian

Mindfulness-Based (MBCT)

Motivational Interviewing (MI)

Narrative

Object Relations

Person/Client-Centered

Positive Psychology

Prolonged Exposure (PE)

Rational Emotive Behavior Therapy (REBT)

Reality Therapy

Relational (Psychodynamic/analytic)

Relational-Cultural Therapy (RCT)

Schema Therapy

Solution-Focused (SFT)

Somatic

Trauma-Focused (TF-CBT)

Other

In 2-4 sentences, please provide a brief description of your practice and approach for Virsentio clients* This field is required.We may share your response with potential clients during our referral process.

Do you have any specific certifications or advanced training in therapy approaches or clinical issues?Please list and include certifying/training body along with date of certification

Over the last year, what percentage of your clients have been men?* This field is required.

100%

80-99%

60-79%

40-59%

20-39%

Fewer than 20%

Please rate your professional competence in the area of men’s mental health issues (you cannot select 7)* This field is required.(0=no competence, 5=average competence, 10=highly specialized)

I'd prefer not to answer

In your experience, what is your greatest strength as a therapist for men, and how does it show up in your work?* This field is required.

Which clinical issues or subgroups of men are you most interested in working with, or would like to see more of in your practice?

Are there specific types of cases or clinical issues you prefer not to work with?

Is there anything else you’d like Virsentio or potential clients to know about you or your practice?* This field is required.