Fill out this questionnaire and mail or email to the address at the bottom.
Name and license:
Contact phone number:
Days & hours clients are seen:
Types of psychotherapy, counseling and any specialties.
Circle those that apply: I work with: Children, teens, adults, Pre-marital couples or divorce, parents, families, blended families or name any other__________________________________
If you take insurance, name which ones_________________________________________
Do you have a sliding scale ____yes ___no?
Do you take credit cards ___yes ____no (if limited, name them)______________?
Check the appropriate box
I work on lifestyle: ___Occasionally ____Often ___Very often
Additional Comments on your work in Adlerian psychotherapy & Counseling:
Other types of work you do:
Please send information to firstname.lastname@example.org or 603 Lake St. #209, Excelsior, MN 55331.