Therapists

If you are a clinician treating clients who have experienced psychological trauma, childhood abuse, or dissociation, the Sidran Institute would like to list your services. To be included in our Therapist Directory, please complete the questionnaire below. There is no charge for inclusion, and we thank you for the work that you do.If you do not have a forms-capable browser, please e-mail us at help@sidran.org or print out the PDF Therapy Resource form and email or fax it to 410-560-0134. Otherwise, please fill out the form online and submit it to us.

*First Name:

Middle Name:

*Last Name:

Degree:
If Other:

*Title:

Company:

*Street Address:

Address 2:

*City: *State:
*Country: *Zip:

*Phone: Ext:

Alternate Phone:

*Fax:

*Email (For administrative purposes only):

Public Email Address (Optional):

Website:

I give permission for Sidran to share the public e-mail address listed above with potential clients:
YesNo

*Have you previously submitted your information: YesNo

*Gender: MaleFemale

Training and Credentials

*Please list degrees, certifications, and other training:

*Please list memberships in professional organizations:

*Have you been censured by any professional licensing body?: YesNo
If Yes, please specify dates and circumstances:

*Do you use hypnosis?: YesNo
If Yes, please specify for what purposes:

*Do you use EMDR?: YesNo

*Do you use “energy therapies” or other complementary treatment approaches?: YesNo
If Yes, please specify for what purposes:

*Do you have advanced training specifically related to the treatment of trauma?: YesNo

*Do you have advanced training specifically related to the treatment of dissociative disorders?: YesNo

Services

Do you provide:
*Individual Therapy?: YesNo
*Group Therapy?: YesNo
*Family Therapy?: YesNo
*Couples Therapy?: YesNo
*Support Groups (Peer-Run): YesNo
*Support Groups (Therapist-Run): YesNo
*Affiliated with a treatment center that provides inpatient services: YesNo
*Are you affiliated with a psychiatrist that provides pharmaceutical support: YesNo

*Populations Served:

*Special Populations Served:

Any Others?:

*Is your office accessible to people with physical disabilities?: YesNo

*Are you fluent in any languages other than English (including ASL for the hearing impaired)?: YesNo

If so, specify:

Do you treat:
*Post Traumatic Stress Disorder?: YesNo
*Dissociative Disorders?: YesNo
*Eating Disorders?: YesNo
*Self-Injury?: YesNo
*Borderline Personality Disorder?: YesNo
*Sleep Disorders?: YesNo
*Depressive Disorders?: YesNo
*Anxiety Disorders?: YesNo
*Substance Abuse/Dual Diagnosis?: YesNo
*Sexual Orientation/Identity Issues?: YesNo
Other relevant specialties?:
[texarea abusespecialties]

Insurance Information

Do you accept:
*Private Insurance?: YesNo
*Medicare?: YesNo
*State Assistance?: YesNo

Do you have:
*Negotiable Fees?: YesNo
*A sliding fee scale?: YesNo
*Do you accept fee only (no insurance)?: YesNo
Please specify which insurance plans you accept:

Write something about yourself or your practice that potential clients would benefit from knowing: this could include your approach, philosophy, background, techniques, or other information. This statement will be shared with prospective clients.