Therapist Resource Form
If you have more than one person at your organization, you will need to have each member at your organization fill one out- OR you will be clumped all together as one person.  
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What is your name? (Without Credentials Please) *
If you are a NON-Therapist Provider?  What type of Provider are you?  (Feel free to put your credentials here if you are a NON-therapist provider ONLY.)  If you are a NON-Therapist, please describe what services you provide here.  
What is your work email? (All lower case please) *
Are you currently offering In-Person Therapy *
Location of Office *
Are you pre-licensed? *
Are you licensed in WA AND OR? *
Are you self pay only? *
Are you paneled with Insurance?  If so, which ones? (please list, even if it's quite a few.  Many people are looking for a specific one!) *
Do you work with Couples, Families or Individuals? *
Required
What age groups do you work with?  Check all that apply. *
Required
Do you have a speciality?   *
What modalities do you utilize? *
Do you provide sliding scale? If so what is your range? *
What is your website? (Without the www. or http:// please!) *
If you are bilingual what other language(s) do you speak?
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