Michigan Counseling Association
|
|
|
- Blaze Reeves
- 5 years ago
- Views:
Transcription
1 Michigan Counseling Association 120 North Washington Square, Suite 110 A Lansing, MI COUNSELOR SUPERVISION INFORMATION General Information & Disclaimer Individuals meeting counselor supervision requirements are eligible to be listed on MCA s Web site. Disclaimer: The MCA provides this list as a service to the profession. MCA neither endorses nor guarantees the credentials of anyone on this list. It is up to the potential supervisee to confirm the supervisor s credential who provides supervision. Please refer to the state law statute for information regarding the law concerning the qualifications of a supervisor. An annual fee of $ is charged to individuals posting their information. The fee is waived for MCA Members in good standing. I. Michigan Counseling Association: Membership Status I am a Member II. Personal Details Title Mr. Gender M Education Masters First Name Heath Last Name Green Address 3415 Ballard Rd. City State Zip Benzonia, MI County Benzie/Grand Traverse greenh@mbcmh.org Phone Number Fax Number III. License Information x LPC LLPC CAC NCC CAAC IV. Specialty Emotional Concerns x Anger x Anxiety/Fear/Panic x x Depression/Bi-Polar x Loss/Grief Relational Concerns Blended Families Communication Friends/Other Parenting x Partner Sexual Problems Stressful Situations Abuse/Neglect E Addiction/Substance Abuse x Anger Management x Attention Deficit/Hyperactivity Chronic/Terminal Illness x Eating Financial x Gambling Infertility Role or Age Sleep Disturbance Victim of Crime
2 Page 2: Green, Heath Specialty - continued Other Academic Adoption/Foster Care Career/Work x Health x Impulse Control Obsessive/Compulsive Sexual Orientation Spirituality x Suicide Co-occuring mental health and substance abuse I. Client Focus Age Specialization Child Adolescent x Adult Elder Setting x Individual x Group x Couple Multicultural Experience Extensive x(w/ extensive traing) Limited Client Gender x Male x Female Transgender Client Sexual Orientation yes Gay, Lesbian, Bisexual, Transgender yes Heterosexual Religious Orientation of your Clients x Any Buddhism Christian Islam Jewish LDS/Mormon I. Supervision Training Received training to satisfy standards of supervision according to the laws in the state of Michigan. Yes
3 Michigan Counseling Association 120 North Washington Square, Suite 110 A Lansing, MI COUNSELOR SUPERVISION INFORMATION General Information & Disclaimer Individuals meeting counselor supervision requirements are eligible to be listed on MCA s Web site. Disclaimer: The MCA provides this list as a service to the profession. MCA neither endorses nor guarantees the credentials of anyone on this list. It is up to the potential supervisee to confirm the supervisor s credential who provides supervision. Please refer to the state law statute for information regarding the law concerning the qualifications of a supervisor. An annual fee of $ is charged to individuals posting their information. The fee is waived for MCA Members in good standing. I. Michigan Counseling Association: Membership Status II. Personal Details Title Gender Education First Name Address City State Zip Phone Number III. License Information LPC LLPC CAC NCC Last Name Fax Number County IV. Specialty Emotional Concerns Anger Anxiety/Fear/Panic Depression/Bi-Polar Loss/Grief Relational Concerns Blended Families Communication Friends/Other Parenting Partner Sexual Problems Stressful Situations Abuse/Neglect Addiction/Substance Abuse Anger Management Attention Deficit/Hyperactivity Chronic/Terminal Illness Eating Financial Gambling Infertility Role or Age Sleep Disturbance Victim of Crime
4 Page 2:, Specialty - continued Other Academic Adoption/Foster Care Career/Work Health Impulse Control Obsessive/Compulsive Sexual Orientation Spirituality Suicide I. Client Focus Age Specialization Child Adolescent Adult Elder Setting Individual Group Couple Multicultural Experience Extensive Limited Client Gender Male Female Transgender Client Sexual Orientation Gay, Lesbian, Bisexual, Transgender Heterosexual Religious Orientation of your Clients Any Buddhism Christian Islam Jewish LDS/Mormon I. Supervision Training Received training to satisfy standards of supervision according to the laws in the state of Michigan.
5 Michigan Counseling Association 120 North Washington Square, Suite 110 A Lansing, MI COUNSELOR SUPERVISION INFORMATION General Information & Disclaimer Individuals meeting counselor supervision requirements are eligible to be listed on MCA s Web site. Disclaimer: The MCA provides this list as a service to the profession. MCA neither endorses nor guarantees the credentials of anyone on this list. It is up to the potential supervisee to confirm the supervisor s credential who provides supervision. Please refer to the state law statute for information regarding the law concerning the qualifications of a supervisor. An annual fee of $ is charged to individuals posting their information. The fee is waived for MCA Members in good standing. I. Michigan Counseling Association: Membership Status II. Personal Details Title Gender Education First Name Address City State Zip Phone Number III. License Information LPC LLPC CAC NCC Last Name Fax Number County IV. Specialty Emotional Concerns Anger Anxiety/Fear/Panic Depression/Bi-Polar Loss/Grief Relational Concerns Blended Families Communication Friends/Other Parenting Partner Sexual Problems Stressful Situations Abuse/Neglect Addiction/Substance Abuse Anger Management Attention Deficit/Hyperactivity Chronic/Terminal Illness Eating Financial Gambling Infertility Role or Age Sleep Disturbance Victim of Crime
6 Page 2:, Specialty - continued Other Academic Adoption/Foster Care Career/Work Health Impulse Control Obsessive/Compulsive Sexual Orientation Spirituality Suicide I. Client Focus Age Specialization Child Adolescent Adult Elder Setting Individual Group Couple Multicultural Experience Extensive Limited Client Gender Male Female Transgender Client Sexual Orientation Gay, Lesbian, Bisexual, Transgender Heterosexual Religious Orientation of your Clients Any Buddhism Christian Islam Jewish LDS/Mormon I. Supervision Training Received training to satisfy standards of supervision according to the laws in the state of Michigan.
CLIENT QUESTIONNAIRE. Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Relationship: Cell Phone:
CLIENT QUESTIONNAIRE Full Legal Name: DOB: / / Preferred Name: Email: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Can we leave voice messages for you at these numbers? Yes Text Messages?
Internship Application Form
Internship Application Form 2018-2019 Full Name: Applicant Information Last First M.I. Date: Other Names Used (Transcript): Preferred Name: Home Address: Street Address Apartment/Unit # City Postal Code
Course 1019 Trans-Disciplinary Ethical Principles & Responsibilities in Professional Counseling
1. Each specific discipline in Professional has ethical codes and standards that reflect common issues and problems which arise in the particular counseling profession. Name at least five important ethical
Steve Barns & Associates The Counseling Center of Denton Bible Church Christian Counseling Services Individual, Marriage, & Family
: Last First MI Male Female / / Age Email: @ Home: ( ) - Cell: ( ) - Address: Street (or P.O. Box) Apt. # City State Zip Code Emergency contact: ( ) - Place of Employment: How long? yrs. mos. Current Marital
Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:
Client Intake Form First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip: Tel: Home: Okay to leave message? (Circle one) Yes No Tel: Work: Ext Okay to leave message? (Circle one)
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone: Private email address: Student? If yes, where and major? May we leave
ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA ( ) NEW CLIENT INFORMATION
Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA. 30062 (404 783-7086) NEW CLIENT INFORMATION Last Name of Client First Name Middle Initial Social Security
M.A. COURSE DESCRIPTIONS
M.A. COURSE DESCRIPTIONS Common Core Curricular Courses CMHC 500 Orientation to Counselor Professional identity and Function (3 hours): This course introduces students to concepts regarding the professional
What To Expect From Counseling
Marriage Parenting Spiritual Growth Sexuality Relationships Mental Health Men Women Hurts and Emotions Singles Ministers and Mentors Technology a resource in: Mental Health What To Expect From Counseling
YMCA of Reading & Berks County Housing Application
YMCA of Reading & Berks County Housing Application Overall Eligibility Criteria To be eligible for these programs (not including SRO), applicants must be: Homeless Drug and alcohol free for at least 5
Sexual Medicine Associates, LLC. presents. SEXMeD
Sexual Medicine Associates, LLC presents SEXMeD An Intensive Educational Experience in Sexual Medicine, Counseling and Therapy for the Health Care Professional October 13th - 20th, 2015 Brazilian Court
Personal Disclosure Statement and Notice of Practices
Sound Therapy of Seattle Lisa Gormley-Leinster, M.A., LMHC, NCC, CCMHC 200 1st Ave West, Seattle, WA 98119 Phone: (206) 659-1738 www.soundtherapyofseattle.com soundtherapyofseattle@gamil.com Personal Disclosure
Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -.
New Client Intake Date: Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -. Employer Email: Emergency Contact Name Relationship Phone number TREATMENT
Name: Birthdate: Gender: Address: Phone: (Home) (Work) (Cell) Highest Education Attended: Occupation: Place of Employment:
CLIENT CLIENT INTAKE FORM Client Information Name: Birthdate: Gender: Address: Is it safe to send correspondence to this address, if needed? Yes No Phone: (Home) (Work) (Cell) Is it safe to contact/leave
Diana Valdez, PhD, LPC
Diana Valdez, PhD, LPC 1701 River Run, Suite 1107, Fort Worth, TX 76107 (817) 332-1425 dianavaldezphd@gmail.com ADULT BACKGROUND Name Date of Birth Street Address City, State, Zip Home/Cell Phone Work
Spiritual Emergence Network c/o Ted Esser P.O. Box , San Diego, CA
Dear Mental or Integrative Health Professional, We are writing to you as part of an ongoing national outreach to mental health professionals interested in working with spiritual and religious issues. Since
Hawaii Psychological Association Diversity Committee and Continuing Education Committee. Present Culturally Responsive Cognitive Behavior Therapy
Hawaii Psychological Association Diversity Committee and Continuing Education Committee Present Culturally Responsive Cognitive Behavior Therapy Presenter: Pamela A. Hays, Ph.D Saturday January 16, 2010
Client Intake History
Client Intake History Brianna Johnston, LMFT 100 Sawmill Rd, Suite 3101 Lafayette, IN 47905 Instructions: To assist in helping you, please fill out this form as fully and openly as possible. All private
Clinical Supervision: Definitions, Roles, and Responsibilities. L. DiAnne Borders Revised
Clinical Supervision: Definitions, Roles, and Responsibilities L. DiAnne Borders Revised 4-22-13 Before you begin Read Borders (1992), Learning to think like a supervisor Reflect on your experiences as
Supervision Professional Disclosure Statement
Supervision Professional Disclosure Statement Thomas A. Field, PhD, NCC, LMHC (WA), LPC (VA) City University of Seattle, 521 Wall Street, Seattle, WA 98121 Office: (206) 239-4767 Fax: (206) 239-4849 E-mail:
New Patient Intake. Boynton Health Mental Health Clinic. If you are new to the mental health clinic or have not been seen in over one year:
New Patient Intake Boynton Health Mental Health Clinic Welcome to the Boynton Health Mental Health Clinic The Mental Health Clinic is open to degree-seeking University of Minnesota Twin Cities campus students
PROPOSED REGULATION OF THE BOARD OF EXAMINERS FOR ALCOHOL, DRUG AND GAMBLING COUNSELORS LCB FILE NO. R069-17I
PROPOSED REGULATION OF THE BOARD OF EXAMINERS FOR ALCOHOL, DRUG AND GAMBLING COUNSELORS LCB FILE NO. R069-17I The following document is the initial draft regulation proposed by the agency submitted on
The NYC Elder Abuse Center
The NYC Elder Abuse Center Brooklyn Geriatric Mental Health and Medical Provider Survey You can also complete this survey online: http://www.surveymonkey.com/s/geriatricproviders PLEASE PRINT CLEARLY Preamble
MERLE MULLINS COUNSELING REGISTRATION FORM (Please Print) CLIENT INFORMATION
MERLE MULLINS COUNSELING REGISTRATION FORM (Please Print) CLIENT INFORMATION Last Name: First: Middle:! Mr.! Mrs. Today s date: / /! Miss! Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid
COUNSELING CENTER ANNUAL REPORT FISCAL YEAR University of Northern Iowa
COUNSELING CENTER ANNUAL REPORT FISCAL YEAR 2016 University of Northern Iowa WELCOME! OUR MISSION The Counseling Center helps students succeed by promoting the personal development and psychological well-being
Career Stages of Health Service Psychologists
Career Stages of Health Service Psychologists Special Analysis of the 2015 APA Survey of Psychology Health Service Providers American Psychological Association Center for Workforce Studies Karen Stamm,
Applicant Total Legal Name. LAC or LPC Required Course Summary For Application
Applicant Total Legal Name LAC or LPC Required Course Summary For Application B Grade or Above Required In Each of the Required 60 Semester Graduate Hours Brick Mortar and Distance Learning Course Work
Common Z-Codes for BHA Services
Specifier Z13.85 Encounter for screening for other diseases/disorders.850 Encounter for screening for traumatic brain injury.89 Encounter for screening for other disorder.9 Encounter for screening, unspecified
CLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
CLIENT HISTORY CLIENT LEGAL NAME: DATE: CLIENT PREFERRED NAME: FAMILY & SOCIAL BACKGROUND Please list and describe your current family members (immediate, extended, adopted, etc.) and/or other members
EDUCATION: 2009 M.A., Azusa Pacific University, Azusa, California (APA Accredited) Master of Arts in Clinical Psychology
Jennifer McWaters, Psy.D. Clinical Psychologist, PSY26521 5055 North Harbor Drive Suite 320, San Diego, CA 92106 Phone 619-275-2286 Fax 619-955-5696 Jen@TherapyChanges.com EDUCATION: 2012 Psy.D., Azusa
College of Psychology and Counseling. Program Overview and Distinctives
College of Psychology and Counseling Program Overview and Distinctives 2018-2019 Hope International University (Updated June 2013; August 2013; updated January 2015; updated 2017) University Mission Statement
Commonwealth of Pennsylvania Office of Mental Health & Substance Abuse Services Application for Membership on OMHSAS Advisory Committees
Commonwealth of Pennsylvania Office of Mental Health & Substance Abuse Services Application for Membership on OMHSAS Advisory Committees This application must be completed by all individuals seeking appointment
BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM
BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM Name Age Preferred first name Address City, State Zip Phone (Day) -_- Cell --_ Email address Occupation (indicate former occupation if retired)
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DIRECTOR S OFFICE BOARD OF PHYSICAL THERAPY GENERAL RULES
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DIRECTOR S OFFICE BOARD OF PHYSICAL THERAPY GENERAL RULES (By authority conferred on the director of the department of licensing and regulatory affairs by
Directory of Utah LGBTQ- Affirmative Psychotherapists
Directory of Utah LGBTQ- Affirmative Psychotherapists All psychotherapists on this list describe themselves as LGBTQ-affirmative. Our organization does not specifically endorse providers on the list. Providers
USING THERAPY AND PSYCHOEDUCATIONAL TECHNIQUES TO SUPPORT INDIVIDUALS WITH DISABILITIES
USING THERAPY AND PSYCHOEDUCATIONAL TECHNIQUES TO SUPPORT INDIVIDUALS WITH DISABILITIES Megan M. Gandolfi MA, LLPC, NCC, Professional Counselor, QIDP Jessica Humiston-Aman MA, LPC, NCC, Professional Counselor,
Demographic Information Form
Demographic Information Form PATIENT INFORMATION Male Female Other / / (Patient Legal Last Name) (Patient Legal First Name) (MI) (DOB) Mailing: SSN#: - - Home Cell Relationship Status (circle one): Single
A New Tomorrow Behavioral Health Services
A New Tomorrow Behavioral Health Services Tara L. Corbett MS, LPC Jenais Y. Means MA, LPC-I Linda L. Leech PhD, LPC, LPC-S Natasha Moseng MS, LPC-I 2635-A Hardee Cove, Sumter, S.C. 29150 Phone: (803) 883-4981
Licensed Professional Counseling
Licensed Professional Counseling S T E P S T O L I C E N S U R E A S A P R O F E S S I O N A L C O U N S E L O R I N T H E U N I T E D S T A T E S : S O U T H D A K O T A - W Y O M I N G South Dakota Earn
C O U P L E S I N T A K E F O R M
COUPLE S INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Address: City: State: Zip: Phone number (cell): (home): (work): Email address: Date of Birth May I leave a voicemail on your cell
Provider Specialty Profile
This profile was created to capture specific information that will allow us to improve our referral process by closely matching member needs with provider services. Please note that incomplete information
Electroconvulsive Therapy Prior Authorization Request
Electroconvulsive Therapy Prior Authorization Request Medicare Advantage To request electroconvulsive therapy (ECT) services, please submit this form electronically at https://www.availity.com or via fax
Let s Talk. About the Role of Schools In Preventing Suicide Among Students
Let s Talk About the Role of Schools In Preventing Suicide Among Students Introductions ANN EPPERSON SCHOOL PSYCHOLOGIST BARREN COUNTY SCHOOLS RACHEL WETTON SCHOOL PSYCHOLOGIST BARREN COUNTY SCHOOLS BRIDGET
MICHIGAN HOME-BASED FAMILY SERVICES ASSOCIATION
Infant Mental Health Endorsement Track Free SW CEUs with paid Conference Attendance MICHIGAN HOME-BASED FAMILY SERVICES ASSOCIATION Home Based Services = Outcomes for Families 26 th ANNUAL CONFERENCE September
Christina Pucel Counseling 416 W. Main St Monongahela, PA /
ADULT INTAKE Name: Gender: M F DOB: Address: City: State: Zip: Telephone: Home Mobile Highest Level Education: Occupation: Emergency Contact: Relationship: Phone: Referred by: Family Members: Name Gender
Mental Health Outpatient Treatment Report Form
Mental Health Outpatient Treatment Report Form INSTRUCTIONS 1. Complete all sections entirely 2. Fax the form to 888-240-4609 / Georgia Families 360º members 888-375-5070 3. You will receive a confirmation
PREJUDICE AWARENESS SUMMIT COMMUNITY FACILITATOR APPLICATION
Please return the application pages to our office via email, fax, or mail by September 22. Information for Applicants Keep this Page! What is the Prejudice Awareness Summit (PAS)? The Prejudice Awareness
Welcome. Important Webinar Feature. Stephen Hebard Counseling Doctoral Candidate UNC Greensboro
Welcome Stephen Hebard Counseling Doctoral Candidate UNC Greensboro Important Webinar Feature Katie Wachtel Counseling Doctoral Candidate UNC Greensboro Strengthening Counselor Identity in Sport to Promote
Los Angeles County PATH: PrEP and TLC+ for HIV Prevention. PATH Community Advisory Board Member Application
Los Angeles County PATH: PrEP and TLC+ for HIV Prevention PATH Community Advisory Board Member Application We would like to invite you to become a member of the PrEP and TLC+ for HIV Prevention (PATH)
ANDREW ELMAN, LPC, ATR
EMPLOYMENT HISTORY ANDREW ELMAN, LPC, ATR 2013-present Veritas Collaborative Durham, NC The Adolescent Program at Veritas Collaborative provides inpatient, acute residential, and partial hospitalization
Essex County Juvenile Detention Center. (PREA) Prison Rape Elimination Act Information & Hotline Numbers
Essex County Juvenile Detention Center (PREA) Prison Rape Elimination Act Information & Hotline Numbers Basic Rules We respect each other s safety. NO verbal or physically abusive behavior ex: (S.M.D)
Provider Specialty Profile
This profile was created to capture specific information that will allow us to improve our referral process by closely matching member needs with provider services. Please note that incomplete information
Journey to Truth Counseling
ADULT / COUPLE INTAKE FORM (Please Print) Date: / / Social Security # Date of birth: Age: Mr. Ms. Dr. Mrs. Miss. Rev. Full Name (Last) (First) (Middle) Parent/Guardian/Power of Attorney: (if applicable)
CONFIDENTIAL. Name Today s Date. Address: City: State: Zip: Phone number (cell): (home): (work): address: Emergency Contact (name): (number):
INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Date of birth Address: City: State: Zip: Phone number (cell): (home): (work): Email address: May I leave a voicemail on your cell or home
Juniata College Health & Wellness Counseling Center INITIAL ASSESSMENT
Juniata College Health & Wellness Counseling Center INITIAL ASSESSMENT DATE Name Date of Birth Age Class Year Email Cell Hometown/State Emergency Contact Emergency Number Gender Identity Race/Ethnicity
Addictive Disorders Assessment Form
Addictive Disorders Assessment Form Thorpe Recovery Centre Telephone: 780.875.8890 Fax: 780.875.2161 Email: info@thorperecoverycentre.org CLIENT INFORMATION First Name Middle Name Last Name Phone Number
Definition of Practice of Massage Therapy - Education Law, Section 7801
License Requirements Definition of Practice General Requirements Fees Partial Refunds Education Requirements Examination Requirement Applicants Licensed in Another Jurisdiction (Endorsement) Limited Permits
PROFESSIONAL MENTAL HEALTH COUNSELING
Professional Mental Health 1 PROFESSIONAL MENTAL HEALTH COUNSELING Professional Mental Health at Lewis & Clark has a longstanding reputation in the community for educating professional counselors who are
SUICIDE PREVENTION FOR PUBLIC SCHOOL PUPILS AND TEACHING STAFF MEMBERS
SUICIDE PREVENTION FOR PUBLIC SCHOOL PUPILS AND TEACHING STAFF MEMBERS Q. What does the law (N.J.S.A. 18A:6-111) require? A. The law requires all teaching staff members to attend two hours of instruction
Client Intake Form. Briefly describe the reason(s) you are seeking psychotherapy at this time:
Client Intake Form Thank you for taking the time to openly and honestly answer the questions below. Your genuine responses are appreciated, as all information provided will assist your therapist to better
Course Catalog. Early Intervention, Treatment, and Management of Substance Use Disorders
Course Catalog To take a course, visit our website at https://www.mindfulceus.com - You can link directly to a course by visiting https://www.mindfulceus.com/course/id where ID is the ID number listed
Crisis Prevention & Intervention Hotline Counselor Application
Crisis Prevention & Intervention Hotline Counselor Application Date of Application Submit completed applications to: Pamela Lee, Volunteer Coordinator volunteer@every-mind.org Fax 301.738.1030 PERSONAL
Heartland Wellness Counseling Health Questionnaire
Heartland Wellness Counseling Health Questionnaire Today s Date: CLIENT INFORMATION Last name: First: Middle: Initial: Nick name: Marital status: Single Married Divorced Separated Widow Social Security
Bastrop Pregnancy Resource Center Client Advocate Application
Bastrop Pregnancy Resource Center Client Advocate Application Personal information First, middle initial and last name Home street address City, state, zip code Home phone Cell Phone Email Occupation Employer
Provider Specialty Profile
This profile w as created to capture specific information that w ill allow us to improve our referral process by closely matching member needs w ith provider services. Please note that incomplete information
Lee Kinsey, Ph.D., LPC Lee Kinsey Counseling 3626 N. Hall St., Ste. 702 Dallas, TX (850)
Lee Kinsey, Ph.D., LPC Lee Kinsey Counseling 3626 N. Hall St., Ste. 702 Dallas, TX 75219 (850) 261-8647 leebkinsey@gmail.com EDUCATION Ph.D. Counseling, August 2015 University of North Texas, CACREP-accredited
A completed application includes the following:! After a successful application review by our staff If you are selected for placement
Dear Prospective Client, N e w L i f e K 9 s Thank you for your interest in being matched with one of our incredible service dogs This packet includes the Assistance Dog Application, Medical History Form
School of Health Sciences. School of Health Sciences Psychology.
School of Health Sciences School of Health Sciences Psychology www.nup.ac.cy UNDERGRADUATE PROGRAMME BSc in Psychology Programme Description The Bachelor of Science in Psychology Programme aims to provide
Dr. Julie A. O Brien LMHC
Dr. Julie A. O Brien LMHC OBJECTIVE: To apply the knowledge acquired from Doctoral studies to edify both graduate and undergraduate students. EDUCATION: Argosy University, Sarasota, Florida Ed.D Counselor
HELLO CAN YOU HEAR ME?
HELLO CAN YOU HEAR ME? IMPORTANT ISSUES FOR TEACHERS WORKING WITH ADOLESCENTS Kristin Walker, M.A. East Tennessee State University Department of Psychology November 6, 2012 Objectives 1. Participants will
Lyris Bacchus Steuber, MS, LMFT MT Harley Lester Lane Apopka, FL Ph: , Fax:
Lyris Bacchus Steuber, MS, LMFT MT 2075 515 Harley Lester Lane Apopka, FL 32703 Ph: 407 417 7770, Fax: 407 862 4820 Please complete the following so I can have a better understanding of how I can help
Vermont Board of Allied Mental Health Practitioners Licensed Clinical Mental Health Counselor. Disclosure for:
Vermont Board of Allied Mental Health Practitioners Licensed Clinical Mental Health Counselor Disclosure for: Michael J. Richards-Bradt, Clinical Intern, Psychotherapist (non-certified) Qualifications
Dear Applicant for Sober Living Environment Registration,
Dear Applicant for Sober Living Environment Registration, Thank you for your interest in Sober Living Registration. The California Consortium of Addiction Programs and Professionals, (CCAPP) endorses the
CURRICULUM VITAE CAROLYN SUTHERBY, LMSW, ACSW
CURRICULUM VITAE CAROLYN SUTHERBY, LMSW, ACSW EDUCATION PhD Candidate Social Work, Anticipated graduation September 2019 Michigan State University East Landing, MI Master of Social Work, April 2002 Grand
APPLICATION TO EMPLOY A
STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY ARNOLD SCHWARZENEGGER, Governor BOARD OF PSYCHOLOGY 2005 Evergreen Street, SUITE 1400 SACRAMENTO, CA 95815-3831 (916) 263-2699 ext. 3303 www.psychboard.ca.gov
New Client Questionnaire: (rev. 08/2016)
New Client Questionnaire: (rev. 08/2016) Client Name: Date of Birth: / / Date of First Session: / / What events or concerns brought you to my office? What goals would you like to accomplish? Are there
COMMUNITY COUNSELING DIRECTORY
Saginaw County COMMUNITY COUNSELING DIRECTORY 2012-2013 PUBLISHED ANNUALLY FOR THE BENEFIT OF OUR COMMUNITY PURPOSE Saginaw County Community Health Authority (SCCMHA) has prepared this guide as a community
Psychiatric Residential Treatment Facility Referral
Psychiatric Residential Treatment Facility Referral Psychiatric residential treatment facility (PRTF) referral information Date of referral: Referral contact: Phone number: Referring facility or agency:
Licensed Professional Counselor & Registered Play Therapist
Emily Keller, PhD, LPC, RPT 659 Edwards Ridge Road Chapel Hill, NC, 27512 (919) 929 1171; ekeller@seinstitute.com Licensed Professional Counselor & Registered Play Therapist INTAKE INFORMATION Client Name:
How does art therapy help people work through with trauma and loss?
How does art therapy help people work through with trauma and loss? Barbara McIntyre, Ph.D., ATR-BC, LPC www.northernmichiganarttherapy.com artstx@freeway.net Definition of Trauma Trauma occurs whenever
ADDICTION TRAINING & WORKFORCE DEVELOPMENT PROGRAM LCADC/CADC STUDENT APPLICATION
New Jersey Prevention Network 150 Airport Road, Suite 1400 Lakewood, New Jersey 08701 Phone: 732-367-0611 Fax: 732-367-9985 E-mail: info@njpn.org Web: www.njpn.org ADDICTION TRAINING & WORKFORCE DEVELOPMENT
MINOR CLIENT HISTORY
MINOR CLIENT HISTORY CLIENT NAME: DATE: FAMILY & SOCIAL BACKGROUND: Please list and describe your child s or teen s current family members (immediate, extended, adopted, etc.) NAME RELATIONSHIP AGE OCCUPATION
Individual Professional Counselors
Individual Professional Counselors CANTON/PLYMOUTH John Becker M.A. LMFT CAAC 734.233.7678 Marriage, Addictions, Family of Origin, Domestic Disputes Lisa Constance, MA, LPC 734.233.9494 Therapy for Individuals,
San Francisco Suicide Prevention LGBT Survey
San Francisco Suicide Prevention LGBT Survey Number of Responses Analyzed: 442 Location: San Francisco Bay Area living in zip code 94xxx 1: What is your age? Under 18 0.5% 2 18-30 10.4% 46 31-40 18.6%
Northside Mental Health Center Intake Questionnaire
Name: _ Date of Birth: Age: SS# Address: City & State: Zip Code: GOALS How may we help you today? What type of help would you like? Circle all that apply Counseling Medication See a doctor What would you
Citrus Health Network, Inc. Post-Doctoral Residency Program Application
Please complete each section by providing as much information as possible. This will better assist in evaluating your application. SECTION I: DEMOGRAPHIC AND EDUCATIONAL INFORMATION A. DEMOGRAPHIC INFORMATION
Application and History for Adult
Application and History for Adult Please print clearly. Complete as much information as possible. This information will be discussed with your counselor. Today s Date: First Name: Middle Initial: Last
2015 Call for Poster Presentations
2015 Call for Poster Presentations Overview We cordially invite you to submit a proposal to present a Poster Presentation at the 2015 Annual Conference for NAADAC, the Association for Addiction Professionals.
ATTUD APPLICATION FORM FOR WEBSITE LISTING (PHASE 1): TOBACCO TREATMENT SPECIALIST (TTS) TRAINING PROGRAM PROGRAM INFORMATION & OVERVIEW
ATTUD APPLICATION FORM FOR WEBSITE LISTING (PHASE 1): TOBACCO TREATMENT SPECIALIST (TTS) TRAINING PROGRAM APPLICATION NUMBER: TTS 2010_2_0011 PROGRAM INFORMATION & OVERVIEW Date of this Application 2/01/10
Risk Assessment. Person Demographic Information. Record the date of admission.
Risk Assessment The following assessment tool is to be used if the person served has made contact with a behavioral health professional and is willing to work with us, to some degree to assess risk. If
San Diego Center for the Treatment of Mood Disorders 1
San Diego Center for the Treatment of Mood Disorders 1 DATE NAME Last Middle First REFERRAL HISTORY: How did you find us (via a referral, web search, recommendation)? Please provide the name and phone
FAMCD Focus. Counseling By Jessica Gonzalez, M.S., FAMCD President-Elect
March 2014 Volume 3, Issue 2 FAMCD Focus Articles in This Issue: Medical Considerations in Counseling Page 1 Multiculturalism and the DSM Page 2 President s Pen Page 1 Max Parker Scholarship Recipient
THE WETC PSYCHOLOGY NEWSLETTER
THE WETC PSYCHOLOGY NEWSLETTER Dr. Bruce Leckart "Find the Truth, Tell the Story" Westwood Evaluation & Treatment Center 11340 Olympic Blvd., Suite 303, Los Angeles, CA 90064 310-444-3154, DrLeckartWETC@gmail.com,
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DIRECTOR S OFFICE BOARD OF PHYSICAL THERAPY GENERAL RULES. Filed with the Secretary of State on
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DIRECTOR S OFFICE BOARD OF PHYSICAL THERAPY GENERAL RULES Filed with the Secretary of State on These rules take effect immediately upon filing with the Secretary
Sexually Addicted Offender Program
1000 Germantown Pike F-5 Plymouth Meeting, PA 19462 610-844-7180 drjenniferweeks@gmail.com Sexually Addicted Offender Program The Sexually Addicted Offender program at SATS is based on the Risk Needs Responsivity
Amanda G. Johnson, LPC
Adult Personal Information Name Date Address Apt City State Zip Code E-mail Is it OK to contact you at this email address? YES NO Home Phone Is it OK to leave a message for you at this number? YES NO Cell
District 5030 Youth Exchange Youth Protection Policy
District 5030 Youth Exchange Youth Protection Policy 1. Statement of Conduct for Working with Youth District 5030 is committed to creating and maintaining the safest possible environment for all participants
Adult Information Form
1 Client Name: Age: DOB: Today s Date Address: City: State: Zip: Home Phone: ( ) Ok to leave message? YES NO Work Phone: ( ) Ok to leave message? YES NO Current Employer (or school if a student): Gender:
Jerry Buie MSW, LCSW University of Utah School of Social Work Salt Lake City, UT Cell:
Jerry Buie MSW, LCSW University of Utah School of Social Work Salt Lake City, UT Cell: 801 557-9203 jerry.buie@socwk.utah.edu Work History August 16, 2013 present: Assistant Professor (Lecturer), College