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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 tracy.howard@sidran.org or print out a PDF version, fill it out, and fax it to us at 410-337-0747. Otherwise, please fill out the form online and submit it to us.
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| Contact Information |
| (*) = required field |
| * First Name : |
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| Middle Name : |
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| * Last Name : |
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| * Degree : |
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| * Title : |
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| Company : |
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| * Street Address : |
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| Second Address (if applicable) : |
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| * City : |
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| * State/Province : |
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| Country : |
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| * Zip/Postal Code : |
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| * Phone : |
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| Extension : |
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| Alternate Phone : |
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| Fax : |
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| * E-mail (for administrative use only) : |
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| Public E-mail Address (optional) : |
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| Website : |
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| I give permission for Sidran to share the public e-mail address listed above with potential clients : |
Yes
No
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| * Have you previously submitted your information? : |
Yes
No
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| * Gender : |
Male
Female
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| Training and Credentials |
| * Please list degrees, certifications, and other training : |
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| * Please list memberships in professional organizations : |
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| * Have you ever been censured by any professional licensing body? : |
Yes
No
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| If Yes, please specify dates and circumstances : |
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| * Do you use hypnosis? : |
Yes
No
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| If Yes, please specify for what purposes : |
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| * Do you use EMDR? : |
Yes
No
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| * Do you use "energy therapies" or other complementary treatment approaches? : |
Yes
No
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| If yes, please describe : |
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| * Do you have advanced training specifically related to the treatment of trauma? : |
Yes
No
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| * Do you have advanced training specifically related to the treatment of dissociative disorders? : |
Yes
No
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| Services |
| Do you provide: |
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| * Individual Therapy? : |
Yes
No
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| * Group Therapy? : |
Yes
No
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| * Family Therapy? : |
Yes
No
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| * Couples Therapy? : |
Yes
No
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| * Support Groups (peer-run)? : |
Yes
No
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| * Support Groups (therapist-run)? : |
Yes
No
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| * Are you affiliated with a treatment center that provides inpatient services? : |
Yes
No
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| * Are you affiliated with a psychiatrist that provides pharmaceutical support? : |
Yes
No
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| * Populations served : |
Children
Adolescents
Men
Women
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| Special populations served : |
Gay/Lesbian
Combat Veterans
Refugees
Ritual Abuse Victims
Offenders (Adult)
Offenders (Juvenile)
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| If Other, please describe : |
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| * Is your office accessible to people with physical disabilities? : |
Yes
No
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| * Are you fluent in any languages other than English (including ASL for the hearing impaired)? : |
Yes
No
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| If so, please specify : |
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| Do you treat: |
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| * Post Traumatic Stress Disorder? : |
Yes
No
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| * Dissociative Disorders? : |
Yes
No
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| * Eating Disorders? : |
Yes
No
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| * Self-Injury? : |
Yes
No
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| * Borderline Personality Disorder? : |
Yes
No
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| * Sleep Disorders? : |
Yes
No
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| * Depressive Disorders? : |
Yes
No
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| * Anxiety Disorders? : |
Yes
No
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| * Substance Abuse/Dual Diagnosis? : |
Yes
No
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| * Sexual Orientation/Identity Issues? : |
Yes
No
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| Other relevant specialties? : |
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| Insurance Information |
| Do you accept : |
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| * Private Insurance? : |
Yes
No
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| * Medicare? : |
Yes
No
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| * State Assistance? : |
Yes
No
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| Do you have : |
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| * Negotiable Fees : |
Yes
No
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| * A sliding fee scale? : |
Yes
No
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| * Do you accept fee only (no insurance)? : |
Yes
No
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| Please specify which insurance plans you accept : |
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| * Therapist Statement |
| 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.: |
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