PSYCHOTHERAPY SAINT LOUIS

Transcription

1 Last Name PSYCHOTHERAPY SAINT LOUIS 1693 S. Hanley Rd. St. Louis, MO (314) NEW MEMBER APPLICATION FORM Welcome to PSYCHOTHERAPY SAINT LOUIS. This application process is the first step toward enjoying all the benefits of PStL membership. There are 2 ways to apply. Choose one: I am signing up on-line (preferred). 1. Click on: and complete the easy on-line application process. 2. Please submit the following items by regular US mail: (a) a copy of your license to practice; (b) a copy of the face sheet of your professional malpractice insurance; (c) your color photo: a JPEG sent as an attachment to PSTL@QABS.COM (d) a check to Psychotherapy Saint Louis for your membership fee. I am signing up using this form. 1. Complete this application form. 2. Please return application with the following items: (a) a copy of your license to practice; (b) a copy of the face sheet of your professional malpractice insurance; (c) your color photo: a JPEG sent as an attachment to PSTL@QABS.COM (d) a check to Psychotherapy Saint Louis for your membership fee. PStL member who referred me:

2 1. Practice Information Do not complete this page if you have signed up on-line. Honorific Circle: Ms. Mr. Mrs. Dr. or write here: First Name Middle Name Last Name Suffix Professional initials Professional Identification Organization Mail Address Mail Suite Mail City Mail State Circle: Jr., III, or write here: As they will appear after your name (circle one) Clinical Social Worker, Counselor, Marriage and Family Therapist, Psychologist, Psychiatrist If any. If different from listed office address, below. Mail ZIP (+4) & Geographical Area Office Address Office Suite Office City Office State Office ZIP (+4) Web site URL Phone Pager (circle one) Inner Suburbs of North of 64, Inner Suburbs of South of 64, South County, West County, To be listed in directory. One location only. List Fax List List Address Certification(s) Areas of Focus* Patients** License Number Degree University Graduation Year Years in Practice Do not List: North County, Do not List: Do not List: We need your address to reduce our communication expenses. Your professional academic degree: Where you earned above degree: When you earned above degree: List Do not List: * You can use terms from the Index Terms page to make your list. ** In any order: infants, preschoolers, children, teens, young adults, adults, seniors

3 2. Practice Description Do not complete this page if you signed up on-line. Below or on a separate sheet or to PSTL@QABS.COM compose a 100-word description of your practice in the third person. Suggestions: check the PStL website for examples written by members. Write in the third-person. You can provide your philosophy of psychotherapy. You can highlight special features of your practice or your setting. You can state if you will offer a discount or other special consideration to patients who find you through PSYCHOTHERAPY SAINT LOUIS. You can give details about your background and training. Please do not repeat material that is on your Information Sheet (Section 1). In order for us to coordinate PStL efforts with other professional organizations, please list your memberships in other local professional associations.

4 3. Index Terms Do not complete this page if you signed up on-line. Areas of Focus Abuse, Physical/Sexual Addictions Adoption Issues AIDS/HIV (affected, infected) Alzheimer's Anger Issues Anxiety Disorders Asperger s Syndrome Attachment Disorder Attention-Deficit Disorder Autism Behavior Problems of Children Bipolar Disorder Chemical Dependence Chronic Illness Depression Dissociative Disorders Divorce Eating Disorders Family Problems Family Violence Gambling Gay/Lesbian Issues Gender Identity Issues Grief/Loss Incest Infertility Internet Relationships Learning Disabilities Marital Conflict Men s Issues Multi-Cultural Issues Obsessive-Compulsive Occupational Problems Pain Parent/Child Problems Personality Disorders Phobia Post-Traumatic Stress Psychosis Rape Relationship Problems Schizoid Personality Self-Esteem Issues Sexual Perpetrators Sexual Problems Shyness Sleep Problems Spiritual Issues Step-Family Issues Stress Suicidal Terminal Illness Traumatic Brain Injury Trauma Trichotillomania (Hair Pulling) Work Issues Women s Issues Populations You Serve Infants Preschoolers Elementary-School Aged Pre-Adolescents Adolescents Young Adults Adults Older Adults Seniors Hearing-Impaired Services You Provide Art Therapy Assertiveness Training Biofeedback* Breath Work Christian Counseling Coaching Cog.-Behavioral Therapy (CBT) Consultation to orgs. Couple Counseling Crisis Therapy Dialectical Behavioral Therapy (DBT) Educational Testing* EMDR* Evaluations Evening Hours Family Therapy Fees, Reduced or Discounted French-Speaking Gestalt Therapy Group Therapy Healing Touch* Hebrew-Speaking Hindi-Speaking Hypnosis* In-Home Therapy Individual Therapy Insight-Oriented Interpersonal Therapy Medication Management* Meditation* Play Therapy Psychoanalysis* Psychodynamic Therapy Reiki* Relationship Therapy Relaxation Training Retreats Solution-Focused Therapy Spanish-Speaking Supervision in Therapy Systematic Desensitization Weekend Hours * By checking this service, I am confirming that I have received special training that has led to a certificate, signifying that I have met the criteria for competency.

5 4. Release I have read, understand, and agree with the Principles of PSYCHOTHERAPY SAINT LOUIS. I give permission for PSYCHOTHERAPY SAINT LOUIS to publish the information I have provided in its Directory of practitioners. I give the editors of the Directory permission to edit my Practice Description for clarity, consistency of tone or length. I certify that the information I have provided is accurate and complete. I will have an opportunity to review my listing for accuracy before publication. I hereby release PSYCHOTHERAPY SAINT LOUIS, their officers, the editor of the Directory, and their employees from any claim for damages to me or my practice that may arise from their publication of information about me or my practice, including claims for damage arising from errors in my listing. Signed Date Fees for New Members Instructions: Circle your fee from the table based on your years of licensure and the time of year you are applying. Individuals who have been licensed 2 years or more Individuals who have been licensed under 2 years Provisionally licensed individuals (required to be under the direction of a supervisor who is a full member of PStL) $325 / year $250 / year $50 / year Your complete application includes all the following: 1. Completed application form (unless you submitted it on-line). 2. Copy of your license 3. Copy of insurance face-sheet 4. Color Photograph you ed to PSTL@QABS.COM. 5. Check made payable to PSYCHOTHERAPY SAINT LOUIS. Mail to PSYCHOTHERAPY SAINT LOUIS 1693 S. Hanley Rd., St. Louis, MO (314) Thank You. Check your application carefully. Incomplete applications delay publication.