The following are all required fields EXCEPT those marked with (*). (This means that you need to enter information in each one before clicking the SUBMIT button at the bottom of the page, UNLESS it is marked with [*].)

To move from box to box, normally you may use your tab key or simply reposition your mouse cursor.

IMPORTANT: DO NOT USE ALL CAPITAL LETTERS when you enter information in the text fields. Use standard upper/lower case instead. Otherwise, your entry may be missed in the searches.

You may submit information on up to two licenses, certifications, or registrations. Please note -- we will use the word "license" to refer to certifications and registrations as well.

LICENSE STATUS:

1. First License:

I am FULLY LICENSED in the area marked below.

Select First License Area (Licensed) Licensed Clinical Social Worker Marriage and Family Therapist Pastoral Psychotherapist Physician: Psychiatrist Psychologist Mental Health Counselor RN: Psychiatric Other: Specify * Other:
AAPC Certified Pastoral Counselors at a Fellow or Diplomate level.
Full Name of License (spelled out):

License Number (do NOT put # or "No."): (ONLY in the case of certifications WITHOUT a number, write "none")

Original Date Issued (mm/dd/yyyy):

Issuing State, Province, Authority (spell out completely):

Select First License Area (Pre-Licensed) Licensed Clinical Social Worker Marriage and Family Therapist Pastoral Psychotherapist Physician: Psychiatrist Psychologist Mental Health Counselor RN: Psychiatric Other: Specify * Other:
AAPC Certified Pastoral Counselor at Member level or below.
Please give us the full name of your pre-licensed status (completely spelled out). For example: Psychology Assistant; Marriage, Family, Child Counseling Intern; Social Work Intern; Pastoral Counseling "Member" Level; and so on:

Registration Number: (do NOT put # or "No."): (ONLY in the case of certifications WITHOUT a number, write "none")

Original Date Issued (mm/dd/yyyy):

Issuing State, Province, Authority (spell out completely):

Full Name of Supervisor (First, Last): (If more than one, please list your primary supervisor only.)

Supervisor's License:
Type: Number:

* 2. Second License:

I DO NOT have a second license.
I am FULLY LICENSED in the second license area checked below:

Second License Area for Licensed Licensed Clinical Social Worker Marriage and Family Therapist Pastoral Psychotherapist Physician: Psychiatrist Psychologist Mental Health Counselor RN: Psychiatric Other: Specify * Other:
AAPC Certified Pastoral Counselors at a Fellow or Diplomate level.
Full Name of License (spelled out):

License Number (do NOT put # or "No."): (ONLY in the case of certifications WITHOUT a number, write "none")

Original Date Issued (mm/dd/yyyy):

Issuing State, Province, Authority (spell out completely):

Select Second License Area (Pre-Licensed): Licensed Clinical Social Worker Marriage and Family Therapist Pastoral Psychotherapist Physician: Psychiatrist Psychologist Mental Health Counselor RN: Psychiatric Other: Specify * Other:
AAPC Certified Pastoral Counselor at Member level or below.
Please give us the full name of your pre-licensed status (completely spelled out). For example: Psychology Assistant; Marriage, Family, Child Counseling Intern; Social Work Intern; Pastoral Counseling "Member" Level; and so on:

Registration Number: (do NOT put # or "No."): (ONLY in the case of certifications WITHOUT a number, write "none")

Original Date Issued (mm/dd/yyyy):

Issuing State, Province, Authority (spell out completely):

Full Name of Supervisor (First, Last): (If more than one, please list your primary supervisor only.)

Supervisor's License:
Type: Number:

AREAS OF PRACTICE EMPHASIS:

You may choose up to six areas of emphasis. We recognize that one's training and experience may generalize legitimately to several areas. Someone who is good with PTSD, for example, may also be skilled at dealing with victims of molest and other physical abuse, as well as certain personality disorders and certain mood disorders. On the other hand, offering too many choices becomes confusing for the public. For data-base search purposes, it is better to make the majority of your selections from our pre-assigned list. Your unique listings will be included and available to the search program, but people may not guess quite as accurately as you would hope.

Important technical note: As long as you leave the popup at the default ("...Area of Practice Emphasis"), the form will read "none" when it comes to us. This is useful if you have less than six areas you wish to select.

First Area of Practice Emphasis: Addictions & Substance Abuse Adolescents Anxiety Career and Job Issues Children Chronically Mentally Ill Co-Dependency & ACA Crisis Counseling Depression Dissociative Disorders & MPD Divorce & Relationship Dissolution Eating Disorders Ethnicity & Multi-Cultural Family & Relationship Therapy Forensics Gay & Lesbian Issues Gender Identity Issues Geriatrics & Gerontology Grief & Loss, Death & Dying Marriage & Couple Therapy Mediation Mens Issues Molest & Other Abuse Recovery Offenders Pain Management Parenting Personality Disorders Persons with Disabilities Post-Traumatic Stress Disorders Self Esteem & Personal Growth Sexual Dysfunction Spirituality & Religious Concerns Step & Blended Families Stress Management Terminally Ill Womens Issues

Second Area of Practice Emphasis: Addictions & Substance Abuse Adolescents Anxiety Career and Job Issues Children Chronically Mentally Ill Co-Dependency & ACA Crisis Counseling Depression Dissociative Disorders & MPD Divorce & Relationship Dissolution Eating Disorders Ethnicity & Multi-Cultural Family & Relationship Therapy Forensics Gay & Lesbian Issues Gender Identity Issues Geriatrics & Gerontology Grief & Loss, Death & Dying Marriage & Couple Therapy Mediation Mens Issues Molest & Other Abuse Recovery Offenders Pain Management Parenting Personality Disorders Persons with Disabilities Post-Traumatic Stress Disorders Self Esteem & Personal Growth Sexual Dysfunction Spirituality & Religious Concerns Step & Blended Families Stress Management Terminally Ill Womens Issues

Third Area of Practice Emphasis: Addictions & Substance Abuse Adolescents Anxiety Career and Job Issues Children Chronically Mentally Ill Co-Dependency & ACA Crisis Counseling Depression Dissociative Disorders & MPD Divorce & Relationship Dissolution Eating Disorders Ethnicity & Multi-Cultural Family & Relationship Therapy Forensics Gay & Lesbian Issues Gender Identity Issues Geriatrics & Gerontology Grief & Loss, Death & Dying Marriage & Couple Therapy Mediation Mens Issues Molest & Other Abuse Recovery Offenders Pain Management Parenting Personality Disorders Persons with Disabilities Post-Traumatic Stress Disorders Self Esteem & Personal Growth Sexual Dysfunction Spirituality & Religious Concerns Step & Blended Families Stress Management Terminally Ill Womens Issues

Fourth Area of Practice Emphasis: Addictions & Substance Abuse Adolescents Anxiety Career and Job Issues Children Chronically Mentally Ill Co-Dependency & ACA Crisis Counseling Depression Dissociative Disorders & MPD Divorce & Relationship Dissolution Eating Disorders Ethnicity & Multi-Cultural Family & Relationship Therapy Forensics Gay & Lesbian Issues Gender Identity Issues Geriatrics & Gerontology Grief & Loss, Death & Dying Marriage & Couple Therapy Mediation Mens Issues Molest & Other Abuse Recovery Offenders Pain Management Parenting Personality Disorders Persons with Disabilities Post-Traumatic Stress Disorders Self Esteem & Personal Growth Sexual Dysfunction Spirituality & Religious Concerns Step & Blended Families Stress Management Terminally Ill Womens Issues

Fifth Area of Practice Emphasis: Addictions & Substance Abuse Adolescents Anxiety Career and Job Issues Children Chronically Mentally Ill Co-Dependency & ACA Crisis Counseling Depression Dissociative Disorders & MPD Divorce & Relationship Dissolution Eating Disorders Ethnicity & Multi-Cultural Family & Relationship Therapy Forensics Gay & Lesbian Issues Gender Identity Issues Geriatrics & Gerontology Grief & Loss, Death & Dying Marriage & Couple Therapy Mediation Mens Issues Molest & Other Abuse Recovery Offenders Pain Management Parenting Personality Disorders Persons with Disabilities Post-Traumatic Stress Disorders Self Esteem & Personal Growth Sexual Dysfunction Spirituality & Religious Concerns Step & Blended Families Stress Management Terminally Ill Womens Issues Other Other:

Sixth Area of Practice Emphasis: Addictions & Substance Abuse Adolescents Anxiety Career and Job Issues Children Chronically Mentally Ill Co-Dependency & ACA Crisis Counseling Depression Dissociative Disorders & MPD Divorce & Relationship Dissolution Eating Disorders Ethnicity & Multi-Cultural Family & Relationship Therapy Forensics Gay & Lesbian Issues Gender Identity Issues Geriatrics & Gerontology Grief & Loss, Death & Dying Marriage & Couple Therapy Mediation Mens Issues Molest & Other Abuse Recovery Offenders Pain Management Parenting Personality Disorders Persons with Disabilities Post-Traumatic Stress Disorders Self Esteem & Personal Growth Sexual Dysfunction Spirituality & Religious Concerns Step & Blended Families Stress Management Terminally Ill Womens Issues Other Other:

RELEVANT PROFESSIONAL ORGANIZATIONS

Please check all clinically relevant organizations:

American Association for Marriage & Family Therapy Name of Division (State or Prov) American Association of Pastoral Counselors If you check the above box, you must choose a region: AAPC Region Atlantic Region Central Region Eastern Region Midwest Region Northeast Region Northwest Region Pacific Region Rocky Mountain-Plains Region Southeast Region Southwest Region American Psychiatric Association Member of State Assoc. Name of State Assoc: American Psychological Association Member of State Assoc. Name of State Assoc:

Association of Clinical Social Workers Name of Local Chapter Association for Transpersonal Psychology California Association of Marriage & Family Therapists In addition, if you are a member of a CAMFT local chapter, please select from the following: CAMFT Chapter Antelope Valley/Santa Clarita Valley Chapter Bakersfield Chapter Central Coast Chapter Chico Regional Chapter Delta-Stockton Chapter Desert Chapter East Bay Chapter Fresno Chapter Inland Empire Chapter Long Beach-South Bay Chapter Los Angeles Chapter Marin County Chapter Monterey County Chapter Mt. Baldy Chapter Nevada County Chapter North County San Diego Chapter Orange County Chapter Redding Regional Chapter Redwood Empire Chapter Sacramento Valley Chapter San Diego Chapter San Fernando Valley Chapter San Francisco Chapter San Gabriel/Pomona Valley Chapter Santa Barbara Chapter Santa Clara Valley Chapter Santa Cruz County Chapter Valley Sierra Chapter Ventura County Chapter National Association of Social Workers Name of Local Chapter (State) Other: Other: Other:

SPECIAL CERTIFICATIONS, TRAINING AND TECHNIQUES:

Please check all that apply:

Board Certified EMDR Guided Imagery

Hypnosis Sand Tray Supervision

Other: Other: Other:

THERAPEUTIC MODALITIES:

You may choose up to four practice modalities. For data-base search purposes, it is better to make the majority of your selections from our pre-assigned list. Your unique listings will be included and available to the search program, but people may not guess quite as accurately as you would hope.

Important technical note: As long as you leave the popup at the default ("...Therapeutic Modality"), the form will read "none" when it comes to us. This is useful if you have less than four areas you wish to select.

Please check up to four:

First Therapeutic Modality: Art Behavioral Brief-Solution Focused Cognitive Communications Eclectic Gestalt Therapy Humanistic-Existential Neuro-Linguistic Programming Object Relations Pastoral Play Psychoanalytic Psychodrama Psychodynamic Self Psychology Systems Transactional Analysis Transpersonal

Second Therapeutic Modality: Art Behavioral Brief-Solution Focused Cognitive Communications Eclectic Gestalt Therapy Humanistic-Existential Neuro-Linguistic Programming Object Relations Pastoral Play Psychoanalytic Psychodrama Psychodynamic Self Psychology Systems Transactional Analysis Transpersonal

Third Therapeutic Modality: Art Behavioral Brief-Solution Focused Cognitive Communications Eclectic Gestalt Therapy Humanistic-Existential Neuro-Linguistic Programming Object Relations Pastoral Play Psychoanalytic Psychodrama Psychodynamic Self Psychology Systems Transactional Analysis Transpersonal Other Other:

Fourth Therapeutic Modality: Art Behavioral Brief-Solution Focused Cognitive Communications Eclectic Gestalt Therapy Humanistic-Existential Neuro-Linguistic Programming Object Relations Pastoral Play Psychoanalytic Psychodrama Psychodynamic Self Psychology Systems Transactional Analysis Transpersonal Other Other:

Please indicate up to two languages in which you are proficient enough to conduct therapy IN ADDITION to English. If you do not select a language, NONE will be assumed.

Select a Language: Cambodian Chinese French German Hmong Korean Italian Japanese Lao Russian Spanish Thai Vietnamese Other Other:

Select a Language: Cambodian Chinese French German Hmong Korean Italian Japanese Lao Russian Spanish Thai Vietnamese Other Other:

* FINANCIAL:

Please check all that apply:

I use a sliding scale. I accept Major Credit Cards. I accept insurance. Other:

* OTHER:

Please use the block below to send us feedback on any aspect of this form and the application process. We promise to read your feedback, but are unable to give individual replies.

OPTIONS FOR ADDITIONAL INTERNET EXPOSURE: Psyfidential's Clinical Registry is a free data base which is rich with searchable information. As a useful tool, it stands on its own. For those seeking additional marketing exposure on the Internet, Psyfidential offers two additional web site options that are proven successful to generate referrals: The most popular is the Multi-Option Web Site (a home page with six linked pages and a large variety of options). These sites include free registration with major search engines. They automatically are linked to the Clinical Registry free of charge. We also offer the Custom Web Site. This is a powerful and flexible presence for an individual with a major program or for a group practice. If you already have your own web site, click here to see how you can obtain a link to it from the Clinical Registry  at a nominal charge. Please use the selection fields below to let us know if you have or plan to have a web site created and hosted by Psyfidential; or if you wish to purchase a link for your web site from the Clinical Registry. Otherwise, please select the last option. (Remember, there is no requirement to purchase anything in order to be listed in the free Clinical Registry.) My Psyfidential Web Site is: http:// My Psyfidential Web Site has been ordered and is pending completion. I plan to apply for a link from my web site to the Clinical Registry. I do not want a Psyfidential Web Site or a Link from the Clinical Registry at this time.

PASSWORD:

Please enter a password so that you will be able to update your Clinical Registry in the future:

Keep a record of this.

In case you lose your password, please supply us with a question to which only you know the answer; and the answer. If you lose your password, let us know and we will send you your question. If you answer correctly, we will forward your password to your e-mail address.
Question:
Answer:

CERTIFICATION:

I certify that the information I have entered on this page is accurate to the best of my ability.
Please enter your initials:
Today's date (mm/dd/yy):

On the next screen, you will be given a chance to review your entries or to return to select an Internet site to be developed, if you so desire.

IMPORTANT: Please hit the SUBMIT button only ONCE. If you need to make changes, do NOT submit a new application but UPDATE this application. Thank you!