Referral Dir.

REFERRAL DIRECTORY

We realize that you are being asked to provide a lot of information, but our aim is to be as complete and inclusive as possible. This Directory will be widely distributed to those who attend our seminars (mental health professionals, lawyers, judges, etc.), and essentially anyone who asks. Of course, with your entry, you will receive a copy as well. We hope to offer an electronic version in addition to the printed version (assuming we can figure out the appropriate technology). The Directory should facilitate practice-building, professional networking, and referrals. This is a small effort directed at bringing together, in a collegial rather than divisive way, mental health resources in our state. Thank you for your participation.

Note: Please check all that apply. Please do not provide information that you do not want published in the Referral Directory. Please try to ensure that all information provided is accurate and clear. If you are uncertain about any of the items, please call Lisa Driscoll at 318-443-0845 or email PTR at ptr@suddenlinkmail.com.

* indicates required fields

*FIRST NAME:

MI:

*LAST NAME:

NICK NAME (if any):

*PREFIX:

Dr.
Mr.
Mrs.
Ms.
Other: ______________

*SUFFIX:

NAME OF BUSINESS:

*MAILING ADDRESS:

*CITY:

*STATE:

*ZIP CODE:

PRIMARY PHONE:

SECONDARY PHONE:

FAX #:

MOBILE PHONE:

EMAIL ADDRESS:

WEBSITE ULR:

OTHER CONTACT INFORMATION:

PSYCHOLOGIST LICENSE #:

LICENSED AS:

Clinical
Clinical Neuropsychologist
Counseling
Developmental
Educational
Emeritus

LICENSED AS cont'd:

A.B.P.P. (American Board of Professional Psychology)
Experimental
Industrial/Organizational
Medical Psychologist
School
Social

SPECIALITY AREA:

Clinical Child & Adolescent Psychology
Clinical Health Psychology
Clinical Neuropsychology
Clinical Psychology
Cognitive & Behavioral Psychology
Counseling Psychology
Forensic Psychology

SPECIALITY AREA cont'd:

Group Psychology
Organizational & Business Consulting Psychology
Psychoanalysis in Psychology
Rehabilitation Psychology
School Psychology
Other: ____________________________________________________________________

SOCIAL WORKER LICENSE #:

LICENSED AS:

Graduate Social Worker
LCSW
LCSW-BACS
Provisional GSW
Registered Social Worker
Other: _____________________

LICENSED PROFESSIONAL COUNSELOR LICENSE #:

LICENSED AS:

Counselor Intern
LMFT
LMFT Supervisor
LPC
LPC Supervisor
MFT Intern
Privileged LPC
Other: ____________________

SUBSTANCE ABUSE COUNSELOR LICENSE #:

LICENSED AS:

Addiction Treatment Assistant
Certified Addiction Counselor
Certified Clinical Supervisor
Certified Compulsive Gambling Counselor
Certified Criminal Justice Professional
Certified Prevention Professional
Counselor in Training

LICENSED AS cont'd:

Licensed Addiction Counselor
Licensed Prevention Professional
Prevention Specialist in Training
Registered Addiction Counselor
Registered Prevention Professional
Registered Preventionist
Other: _____________________

VOCATIONAL REHABILITATION COUNSELOR LICENSE #:

LICENSED AS:

Licensed Professional Vocational Rehabilitation Counselor
Licensed Professional Vocational Rehabilitation Counselor -- Supervisor
Provisional Licensed Professional Vocational Rehabilitation Counselor
Other: _____________________

AGE GROUPS (check all that apply):

Infants/Toddlers
Pre-School
School-Age
Early Adolescence
Mid-Adolescence
Late-Adolescence
Young Adults
Adults
Mid-Life
Late-Life

THERAPY MODALITIES (check all that apply):

Family Therapy
Group Therapy
Individual Therapy
Marital Therapy
Marriage & Family Therapy
Other _____________________
Other _____________________
Other _____________________
Other _____________________
Other _____________________

SPECIFIC THERAPIES OFFERED (check all that apply):

Adolescent Therapy Group
Behavior Therapy
Client Centered Therapy
Cognitive/Behaviorl Therapy
Crisis Intervention
D.B.T. (Dialectical Behavior Therapy)
E.M.D.R. (Eye Movement Desensitization Reprocessing)
Grief Counseling
M.S.T. (Multisystemic Therapy)
Men's Therapy Group

SPECIFIC THERAPIES cont'd:

Parent Training
Psychodynamic Therapy
Trauma-Focused Therapy
Women's Therapy Group
Other _____________________
Other _____________________
Other _____________________
Other _____________________
Other _____________________
Other _____________________

DIAGNOSTIC GROUPS (check all that apply):

Addictive Disorders
Adjustment Disorders
Affective (Mood) Disorders
Anxiety Disorders
Cognitive Disorders (e.g., Delirium, Demential, Amnestic Disorders)
Communication Disorders
Disruptive Behavior Disorders
Dissociative Disorders

DIAGNOSTIC GROUPS cont'd:

Eating Disorders
Elimination Disorders
Factitious Disorders
Gender Identity Disorders
Impulse-Control Disorders
Learning Disorders
Personality Disorders
Pervasive Developmental Disorders

DIAGNOSTIC GROUPS cont'd:

Psychotic Disorders
Sexual Disorders
Sexual Dysfunctions
Sleep Disorders
Somatoform Disorders
Substance Related Disorders

After filling the details click on the SUBMIT button.

Professional Training Resources, Inc - 212 Edgewood Dr., Pineville, LA., 71360
(318) 443-0845 or 888-229-8128

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