Programs Questionnaire - Amudim

As Amudim prides itself on maintaining the most up to date information so we can best serve our clients, we ask that you please complete this form, so that we can keep our database as up to date as possible.

Question for researching programs

Name of Program *

Website/URL

Please enter your programs Mission Statement

What year was your program established?

Program Location:

City

State *

Country *

Does your program have multiple locations?

Yes

No

Second Location City

Second Location State

Second Location Country

Third Location City

Third Location State

Third Location Country

Name of Program Director *

Name of Clinical Director

Primary Contact Person information:

Name

Email *

Office Number:

Cell Phone Number:

For Amudim Internal Use Only

Please enter information about your program:

Genders Served *

Male

Female

Co-ed

Is this program LGBTQ+ friendly? *

Yes - All Inclusive

Yes - Not including the Trans Community

No

OtherOther

Program Type: *

Inpatient

Outpatient

Both

For your PHP/IOP does your program offer housing?

Yes

No

What is the cost of housing for the PHP/IOP Program?

Age of clients served *

Under 10 Years Old

10 - 15 Years Old

16 - 18 Years Old

19 - 22 Years Old

23 - 30 Years Old

30 - 50 Years Old

Above 50 Years Old

OtherOther

Average length of the program *

28 Days

Up to 3 months

Up to 6 months

Up to 12 months

Greater than 1 year

OtherOther

Areas addressed (select all that apply) *

Addiction

Anxiety

Death of a Loved One

Depression

Divorce

Domestic Violence

Eating Disorders

Emotional Abuse

Food Addiction

Gambling Addiction

Internet Addiction

Mental Health

OCD

Other Trauma

Physical Abuse

Porn Addiction

Self Harm

Sex Addiction

Sexual Abuse

Substance Abuse

Suidical Ideations

Trauma

OtherOther

What treatment modalities does your program offer?

Acceptance & Commitment Therapy (ACT)

Attachment Based Behavioral Therapy (BT)

Child-Centered Play Therapy (an Evidence-based practice)

Christian Perspective Therapy

Client/Person-Centered Therapy

Cognitive Behavioral Therapy (CBT)

Dialectical Behavioral Therapy (DBT)

Emotionally Focused Therapy (EFT) for Couples

Emotional Freedom Techniques (EFT)

Existential Phenomenological Psychotherapy

Experiential Therapy

Eye Movement Desensitization and Reprocessing (EMDR)

Family Systems Therapy

Gottman Couples Therapy

Grief Therapy

Humanistic Therapy

Integrative (technical eclecticism) Therapy

Internal Family Systems (IFS)

Interpersonal Neurobiology (IPNB)

Jungian Psychotherapy

Life Transitions Therapy

Mindfulness-Based Cognitive Therapy (MBCT)

Modern Psychoanalytic Therapy

Motivational Interviewing Therapy

Multicultural Therapy

Neurofeedback

Narrative Therapy

Object Relations Therapy Based Psychotherapy

Person & Family Centered Therapy

Play Therapy

Polyvagal Theory Informed Therapy

Psychodynamic Therapy

Relational Life Therapy (RLT) for Couples

Solution-Focused Brief Therapy (SFBT)

Somatic Experiencing (SE)

Spiritual Integration Counseling

Strength-based Therapy

Structural Family Therapy

Trauma Focused Therapy

OtherOther

Cost of program in USD

Daily Rate

Weekly Rate

Monthly Rate

Cost of Initial Intake in USD (if applicable)

Initial Intake Rate for Daily Program

Initial Intake Rate for Weekly Program

Initial Intake Rate for Monthly Program

Do you accept insurance? *

Yes

No

Please specify which insurance you accept and specify if it is for RTC, PHP, IOP or all:

Do you work with "Out of Network" providers? *

Yes

No

Please specify which "Out of Network" insurance work best with you program and specify if it is for RTC, PHP, IOP or all:

Do you require the client to pay upfront?

Yes

No

OtherOther

How much does the client have to pay upfront?

Is your program exclusively private pay?

Yes

No

How is insurance billed?

In-House

3rd Party

Does your program offer a sliding scale?

Yes

No

Does your program offer a standard discount For Amudim clients?

Yes

No

What is the Discount Rate? Please specify for RTC, PHP and IOP

Does your program assist clients in obtaining Single Case Agreements from their insurance providers?

Yes

No

Does your the program offer scholarships?

Yes

No

Does program offer kosher food?

Yes

No

Is there any added costs for kosher food?

Yes

No

Does your program offer Kosher for Passover food?

Yes

No

Does your program offer any religious programming (including bringing in outside clergy)?

Yes

No

For what religious denominations?

If you would like to add any additional comments about your program, please do so below:

If you are human, leave this field blank.

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