Application for Custom or Enhanced Web Page

If you are creating a complete web page, we will require as much of the information as you can fill in. If you are doing an Enhanced page, we will require the Administrative Information, the personal paragraph, and any other information you would like to add, realizing, however, not all of it will be used.

Administrative Information: For billing and qualifying information, only.

Specify Type:	Enhanced (example) Custom Web Page (example)	Remember NOT to use the ENTER key. That will cause submission of data. Use the TAB key throughout.
Contact Name:
Contact Mailing Address:
City, ST Postal Code:
License Number:
Contact Phone Number:
E-mail address:

Web Page Preparation: (if you are creating an Enhanced page, you may enter this information but not all of it will be used. Entry of data will help us assess how best to fill that Enhanced page.

Name(as it will appear on the page):
Name of Business (if any):
Address:
City, State & Postal code:
Phone Numbers you wish listed:
Individual/Voicemail:
Business or Office:
Pager:
E-mail:
Years in Practice:
Degrees: (Please do not abbreviate)
	School:
	School:
	School:
Licenses:



Languages other than English:
Services Offered: (Check or enter up to six)
Adolescent Counseling	Child Counseling
Classes	Couples Counseling
Family Counseling	Groups
Individual Counseling	Relationship Counseling
Other:	Other:
Theoretical Orientation(s):	You may select multiple modalities by holding down the CTRL key as you click on each selection
If you don't see your orientation or modality for therapy, please use the blank below to enter the data.
Other:
Memberships to be listed:

Areas of Emphasis: (Check or enter up to ten. An even number will look best on your page.)
Addictions	Ethnicity/Multi-cultural	Parenting
Alternative Lifestyles	Family Law	Personality Disorders
Anxiety	Forensics	PTSD
Chronically Mentally Ill	Gay/Lesbian Issues	Religious Issues
Co-dependency	Geriatrics	Sand Tray/Play Therapy
Crisis Counseling	Grief/Loss	Self Esteem/Growth
Depression	Hypnosis	Sexual Dysfunction
Disabilities Counseling	Issues of abuse	Spiritual Issues
Dissociative Disorders/MPD	Life Transitions	Step/Blended Families
Divorce Counseling	Mediation	Stress Management
Eating Disorders	Meditation	Terminally Ill
EMDR	Men's Issues	Twelve Step
Employment	Pain Management	Women's Issues
Other:	Other:	Other:

If you have selected the Enhanced web page, please write a personal paragraph of 150-200 words. This will be placed on your page.