Application Form test


    Personal Information

    *First Name:

    *Last Name:

    Street Address :

    *City:

    *Province:

    *Postal Code:

    *Home Phone:

    Work Phone:

    Ext:

    Cell Phone:

    Fax:

    *Email:

    Website:

    Gender

    Professional Association(s):

    Membership #:

    Insurance receipts provided (please check all that apply):

    Psychotherapist Permit:

    Permit #:

    No. of Years in Practice :

    Office Hours

    Please indicate days and hours available (including evenings and weekends).

    Monday

    Hours

    Tuesday

    Hours

    Wednesday

    Hours

    Thursday

    Hours

    Friday

    Hours

    Saturday

    Hours

    Sunday

    Hours

    University Degree(s)

    Please check all that apply.

    Please indicate discipline :

    Please indicate discipline :

    Please indicate discipline :

    Additional Training

    (i.e. post-graduate training programs, EMDR, hypnosis, in which a certificate of completion was attained.)

    Malpractice Insurance

    COMPANY :

    Languages Offered in Therapy

    Applicable Title(s) to Your Profession

    Theoretical Orientation(s)

    Areas of Specialty

    Addictions

    Adolescent Issues

    Eating Disorders

    Anxiety Disorders

    Disruptive Behaviour Disorders

    Chronic Health/Terminal Illness Issues

    Marital Issues

    Parenting Issues

    Geriatric Issues

    Cultural Issues

    Trauma

    Mood

    Psychotic Disorders

    Personality Disorders

    Cluster A

    Cluster B

    Cluster C

    Family of Origin Issues

    Sexuality

    Career Counseling

    Personal Growth

    Pervasive Developmental Disorders

    Other Areas of Specialty

    Treatment Modalities

    Types of Clients Treated

    Ages to

    Are you willing to see clients who are court mandated or referred by DYP?

    Groups
    If you run therapeutic or psychoeducational groups, please provide an outline in the space below.

    1. Title:

    Brief Description :

    Member Criteria :

    2. Title:

    Brief Description :

    Member Criteria :

    3. Title:

    Brief Description :

    Member Criteria :

    Are you willing to travel to see clients in the surrounding areas of Montreal?

    Do you provide telephone sessions?

    Would you be open to providing online therapy?

    Do you see clients in their own home?

    Do you provide workshops or other training in your areas of specialty?

    Please list the titles of the trainings or workshops that you could provide

    Are you willing to provide educational presentations to local community groups?

    Please list the titles of the presentations that you could provide

    Please use this section to outline any additional information you believe would assist is defining the types of referrals you would most like to receive :

    Resume

    Please attach your resume

    Signature of applicant: