Download the questionnaire here,

or fill out the questionnaire below, print, and mail it to the address at bottom.

Name and license:

Business Name:

Business Address:

Contact phone number:

E-mail

Website address:

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 adlerian.network@gmail.com or 2560 Alabama Ave. S., St. Louis Park, 55416.