Personal Information

*First Name:
*Last Name:

Street Address :

*City:
*Province:
*Postal Code:

*Home Phone:

Work Phone:
Ext:

Cell Phone:

Fax:

*Email:

Website:

Gender


Date of birth

(DD-MM-YYYY)

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


For Internship Applications please specify Type:

Other (please specify) :

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?

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

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: