Date of birth
No. of Years in Practice :
Please indicate days and hours available (including evenings and weekends).
For Internship Applications please specify Type:
Please check all that apply.
(i.e. post-graduate training programs, EMDR, hypnosis, in which a certificate of completion was attained.)
Languages Offered in Therapy
Applicable Title(s) to Your Profession
Disruptive Behaviour Disorders
Chronic Health/Terminal Illness Issues
Pervasive Developmental Disorders
If you run therapeutic or psychoeducational groups, please provide an outline in the space below.
Please list the titles of the trainings or workshops that you could provide
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 :