Therapist 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 Private Therapist

Name of Therapist *

Therapist Certification with the Month and Year of Certification

MSWMSW

LMSWLMSW

LCSWLCSW

CSATCSAT

Ph.D.Ph.D.

Psy.DPsy.D

MHCMHC

CASACCASAC

LMHCLMHC

LCMHCLCMHC

LMHPLMHP

LCPCLCPC

MDMD

NPNP

OtherOther

Are there other therapists in your practice?

Yes

No

Please list their name and their level of certification:

Name of the practitioner who provides your supervision:

Name of Practice (if applicable)

What year was your practice established?

Please enter your Mission Statement:

Website/URL

Program Location:

City

State *

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

Services Offered: *

Individual Therapy

Family Therapy

Group Therapy

Marriage Counseling

Psychiatry

Name of the Practitioner:

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

What languages do you provide services for *

English

Yiddish

Hebrew

Spanish

Russian

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

Please select the modalities you or other therapists in your practice are trained in:

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 treatment in USD

Individual Therapy

Family Therapy

Group Therapy

Marriage Counseling

Psychiatry

Cost of Intake in USD (if applicable)

Individual Therapy Intake

Family Therapy Intake

Group Therapy Intake

Marriage Counseling Intake

Psychiatry Intake

Do you accept insurance? *

Yes

No

Please specify which insurance you accept and specify if it is for Individual Therapy, Family Therapy, Group Therapy, Marriage Counseling, Psychiatry or all

Are you exclusively private pay?

Yes

No

How is your insurance billed?

In-House

3rd Party

Do you provide a Superbill for out of network reimbursement?

Yes

No

Do you offer a sliding scale?

Yes

No

Does your program offer a standard discount for Amudim clients

Yes

No

What discount do you offer for Amudim clients?

Do you assist clients in obtaining Single Case Agreements from their insurance?

Yes

No

Do you offer scholarships?

Yes

No

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

If you are human, leave this field blank.

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