Referral Information Request

Referrals to Private Practice

If you do not have a Private Practice please skip to the next section by Clicking Here
 
Name of Practice:
Private Practice Address:    
Apt, Box, Suite:
Parish:
City:
State:
Zip code:
Private Practice Landline: Can we make this public? Yes   No
Cell phone:   Can we make this public? Yes   No
Best time(s) to call:

Referrals to Place of Employment

If you have a Private Practice and practice as part of employment, please also list your Place of Employment information
 
Job Title:  
Job/ Place of Practice:
Job Address:    
Apt, Box, Suite:
Parish:
City:
State:
Zipcode:
Job Landline: Can we make this public? Yes   No
Cellphone:   Can we make this public? Yes   No
Best time to call:
What are the requirements/ criteria for a referral to your place of employment? (If this information is posted on a website please be sure to include the URL address for us to give to others.)
What are the requirements/ criteria for a referral to your private practice? (If this information is posted on a website please be sure to include the URL address for us to give to others.)
Does your job offer services for children? Yes   No
Does your practice offer services for children? Yes   No
Does your job offer psychological assessment services? Yes   No
List the mental health services your place of employment offers.
List the types of clients and services you take in your private practice.
Can you take any probono cases at this time? Yes   No
Are you interested or able to work with referrals from the religious/spiritual community? Yes   No
Do you have a working knowledge plus a comfort level with the following religious perspectives?  Check those whose religious tenets you have knowledge of and whose religious framework you are comfortable working in. Muslim
 Buddhist
 Hinduism
 Islamic
 Afro-Carribean (Voodoo)
 Afro-Atlantic (Santaria)
Can you conduct mental health services in any of the following languages? French
 Spanish
 Vietnamese
 Korean
 Any Native American languages
    Which ones?
Can we place this information that you've shared with us on a referral list that we will make publicly available?

 

 Yes   No
Do you wish to receive information by email about the toolkits that we will develop? Yes   No
Are you interested in additional mental health training? What would you like training in that would be helpful to you in the rebuild effort and reducing mental health and substance abuse problems.
 
Any comments that you would like to share with us about the overall training experience?

 

THANK YOU!