Adlerian practitioners: Fill this out and we’ll add you to our directory.

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.