If you run psychotherapy or processing groups for people who have experienced psychological trauma, childhood abuse, or dissociation, the Sidran Institute would like to list them in our Trauma Resources Database. To be included, please complete the questionnaire below. There is not 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 410-560-0134. Otherwise, please fill out the form online and submit it to us.
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| (*) = required field |
| * Contact name : |
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| * Street Address : |
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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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| * Fax : |
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| * E-mail : |
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| Website : |
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| Intake/Contact Person : |
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| * Populations served : |
Children
Adolescents
Adults
Males only
Females only
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| * Specializations : |
Post Traumatic Stress Disorder
Dissociative Disorders
Combat
Sexual Abuse/Rape
Eating Disorders
Self-Injury
Borderline Personality Disorder
Sleep Disorders
Depression
Anxiety
Substance Abuse/Dual Diagnosis
Sexual Orientation/Identity Issues
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| Other relevant specialties : |
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| Philosophical Orientation (e.g. spiritual/religious) : |
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| * Do you run therapy groups? : |
Yes
No
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| If yes, please describe the groups you sponsor : |
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| What is your experience, including your credentials, for running these groups? |
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| * Do you sponsor peer-run support groups? : |
Yes
No
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| If yes, please describe : |
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| Briefly state your treatment philosophy. What issues does your program focus on and how do you treat them? : |
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| Institutional Information |
| * Is your program affiliated with a hospital or medical center? : |
Yes
No
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| If yes, please name the institution and describe the relationship : |
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| * What types of insurance do you accept? : |
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| Does your Center/Program provide |
| * Financial assistance? : |
Yes
No
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| * Sliding Fee Scale? : |
Yes
No
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| * Payment Plans? : |
Yes
No
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