Counselor Directory Sign-Up Form

TELL US A LITTLE ABOUT YOURSELF/YOUR PRACTICE
Primary Professional's First Name
Primary Professional's Last Name Note: DO NOT add degrees here - see below
Gender	F M
Name of Practice
Business Address
City
State Note: Leave BLANK if you're not USA E-mail us with your Country Name
County/Region
Zip Code
Business Phone
Business Fax
E-mail name@isp.com	(required ONLY to validate)
Your Website Address

ABOUT YOUR PRACTICE
Title describing you/your practice
Type of Practice
Number of Professional Staff
Years in Practice

PAYMENT(S) ACCEPTED
(ie, Medicaid, Medicare, Most Insurance, Sliding Scale, Set Cash fee)

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DEGREE(S)
use abbrev only: ie. MA, MEd, MSW, RN, Pharm.D, Psy.D, RN,BSN

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LICENSE(S) & CERTIFICATION(S)
please write out the full license/certification & abbrev
ie: Master Addictions Counselor, MAC

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SPECIALITIES / AREAS OF EMPHASIS / COMPETENCY Note: You will be searchable by these. We apologize if not all are listed, add them in your TEXT SUMMARY below
Anxiety/Panic Attacks Crisis Counseling Chronically Mental Ill Chronic Illness Codependency/ACA Dissociative Disorders (MPD/Repressed Memories) Divorce/Dissolution Eating Disorders Employment Issues Forensics Gambling Gay/Lesbian Issues Grief/Loss Mediation	Men's Issues Mood Disorders (Depression/Bipolar) Multicultural Issues Pain Management Parenting Personality Disorders Persons with Disabilities Self Esteem/Personal Growth Sexual Disorders Substance Abuse/Dependency Schizophrenia & Delusional Disorders Terminally Ill Trauma Recovery (abuse) Women's Issues

AREAS MOST OFTEN WORKED IN
ie: children, adults, aging, couples, groups, testing, medications

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THEORETICAL ORIENTATION
ie: brief therapy, existential, communications, cognitive, eclectic

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PROFESSIONAL ASSOCIATION MEMBERSHIPS
ie: Counseling Associations, Psychological Associations

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LANGUAGES SPOKEN OTHER THAN ENGLISH
ie: Spanish, French, Japanese

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enter up to 500 words detailing more about your practice.
use CAPITOL LETTER headings such as:
SERVICES, PHILOSPHY, MISSION, OFFICE HOURS, etc.
-->Use double hard returns to separate information.

Select 1 of the 3 Listing Types Free, or mail us $10 for a graphic
	FREE	general graphic	Free Graphic supplied by All About Counseling

	*add a graphic: $10.00 Thanks!	you email to us your photo/logo	When you hit SUBMIT at the bottom, you'll be e-mailed instructions on where & how to send your image & payment.

Important Information

Note: to make changes it is necessary that you request in e-mail to us that we delete your entire listing, then you can re-enter your entire listing as desired.
Therefore, please take time to proof your listing before you submit:
- Check spelling & capitalizations.
- Did you enter degrees after your name, and also IN the degree fields? If so, delete degrees after your name.
- Did you use DOUBLE hard returns in your summary to separate info? If not, info will crunch into 1 paragraph.
*A lifetime listing: means you will be listed for the lifetime that All About Counseling continues its web presence.
- If you select to have a graphic it will become visible after payment is received
- You will receive one automatic e-mail after you submit your listing, then we won't e-mail you again.

When you submit your listing, you'll
be sent an automatic e-mail with instructions
on how to add a graphic to your Listing

To prevent false entries, please ENTER the numbers and letters seen in gray box