Therapist Informational Form | Project Intersect

Therapist Information

^*Required fields

Last Name *

First Name *

Middle Initial or Name

Agency or Organization

If you in private practice, please indicate here. If you work for an agency or organization and ALSO have a private practice, please complete this form separately for each practice setting.

Primary/Mailing Address

Address Line 2

City

State

Zip

Check this box if you do not want your address to be available on the public site.

Phone *

Email *

Check this box if you do not want your email to be available on the public site.

Website

Professional Credentials

Degree (s) as you would like it displayed (e.g. PhD, PsyD, MA, MS): *

Degrees as you would like them displayed

It is suggested that you list the highest educational degree earned that is relevant to the professional services provided.

Degree Field of Study (SW, MFT, Counselor Education, Prof. Counseling, etc.):

Degree Field of Study

There are a range of Educational Programs and Fields of Study leading to a career in mental health counseling and psychotherapy. Psychology, Social Work, Counseling, Marriage and Family Therapy are some of the most common, but there are a number of other relevant programs and titles. Please list your primary educational and training program.

Licensure: *

Are you TF-CBT Certified? *

Yes

No

TF-CBT Certified

To be TF-CBT Certified you must meet specific requirements established by the developers of TF-CBT and complete the certification and registration process. There are training, consultation, experience, and knowledge elements in the certification requirements.

If you think you are eligible and would like to register to become certified please go to the TF-CBT Certification website: https://tfcbt.org/

Other Mental Health-related Professional Certifications (e.g. NCC, RPT):

Other Mental Health Certifications

For this field we would like you to put any certification that you currently hold that assists in your mental health treatment of children and adolescents. Professional/board certifications earned that involve an evaluation of clinical competence and expertise are particularly relevant.

TF-CBT Training

Completed Foundations TF-CBT Training

Completed Keystones TF-CBT Training

Other Basic TF-CBT Training (Not Project Intersect Sponsored)

Project Intersect

Please indicate if you have completed the TF-CBT Trainings sponsored by Project Intersect. “Completion” of Foundations requires participation in the in-person training days and meeting the consultation call and client requirements. If you are unsure if you have met these requirements contact Susannah Fulling () or your Trainer/Consultant. “Completion” of Keystones requires .

Additional Languages

Do you offer services in a language other than English?

Yes

No

If yes, please list the language(s):

Level of Care

Level of Care (check all that apply) *

Psychiatric Residential Treatment Facility

Other Residential Treatment Facility

Outpatient Services

In-home Services

Services provided at Group Home/RBWO

Services provided at CSEC-specific Group Home

Level of Care

Please indicate all of the settings in which you provide service (that a client can be referred). Check all that apply. If you are uncertain what to indicate, please describe in the “Other” box and/or contact Susannah Fullling for clarification.

Zip codes(s) of Psychiatric Residential Treatment Facilities:

Zip code(s) of Psychiatric Residential Treatment Facilities

We have asked for zip codes instead of street addresses to protect organizations and therapists in our database who work in undisclosed locations for the safety and security of their clients and staff. This field is intended to help others identify potential therapists when geographic location or service area is a consideration. Searchers will be provided with an approximate distance from their actual location to the listed zip code(s).

Zip codes(s) of Other Residential Treatment Facilities:

Zip code(s) of Other Residential Treatment Facilities

We have asked for zip codes instead of street addresses to protect organizations and therapists in our database who work in undisclosed locations for the safety and security of their clients and staff. This field is intended to help others identify potential therapists when geographic location or service area is a consideration. Searchers will be provided with an approximate distance from their actual location to the listed zip code(s).

Zip codes(s) of Outpatient Service Facilities:

Outpatient Service Facilities

We have asked for zip codes instead of street addresses to protect organizations and therapists in our database who work in undisclosed locations for the safety and security of their clients and staff. This field is intended to help searchers identify potential therapists when geographic location or service area is a consideration. Searchers will be provided with an approximate distance from their actual location to the listed zip code(s).

See Geographic Service Areas served (below)

Zip codes(s) of Group Home/RBWO Facilities:

Zip code(s) of Group Home/RBWO Facilities

We have asked for zip codes instead of street addresses to protect organizations and therapists in our database who work in undisclosed locations for the safety and security of their clients and staff. This field is intended to help others identify potential therapists when geographic location or service area is a consideration. Searchers will be provided with an approximate distance from their actual location to the listed zip code(s).

Zip codes(s) of CSEC-specific Group Home Facilities:

Zip code(s) of CSEC-specific Group Home Facilities

We have asked for zip codes instead of street addresses to protect organizations and therapists in our database who work in undisclosed locations for the safety and security of their clients and staff. This field is intended to help others identify potential therapists when geographic location or service area is a consideration. Searchers will be provided with an approximate distance from their actual location to the listed zip code(s).

Other, please describe:

Geographic Areas Served

Note: At least one checked box is required for this section.

Counties Served (check all counties served): *

Provide any additional description of service area, geographic area served, or other service parameters:

Provide any other description of service area, geographic area served or any other parameters.

This field is to indicate if there are any other limits on who you can serve based on geography. Examples include

“My organization serves 11 counties but I only practice in 3.”

I am limited by driving time- 1 hr from my office.”

“Clients must be a resident of Fulton County.”

“No ‘out-of-state’ referral s accepted”

Services Offered

Services offered by you (check all that apply): *

Additional services offered by you or your organization (check all that apply): *

If you indicated 'Other' for additional services, please list or describe:

Payment Information

I/My organization's billing and/or insurance acceptance (check all that apply): *

Payment Information

VOCA reimbursement
The Victims of Crime Act and Georgia Crime Victims Compensation Program helps victims and their families through the emotional and physical aftermath of crime by providing financial benefits for expenses, including mental health counseling. Therapy treatment for CSEC victims may be covered by VOCA funds. Note that payment is by reimbursement for services delivered and is not made in advance of service provision.

To learn more about VOCA, how to apply for VOCA funding, and how clients may apply, please follow the link: http://cjcc.georgia.gov/victims-compensation

Pro bono
Many CSEC clients do not have insurance coverage or other system involvement that pays for services (DJJ, DFCS) and their caregivers do not have the financial means to pay for treatment services. Please check this box if you would consider seeing a client pro bono. By doing so you are NOT committing to agree to do so under any circumstances or for any client.

List private insurance plans accepted:

Please describe sliding scale:

Please describe other charge/payment options:

Referral Process

Please describe the referral process in detail: *

If there is a specific contact person other than you, please identify below:

Name

Phone

Email

Do you have a referral form?

Yes

No

If you have a referral form, please upload a copy here:

Maximum file size: 33.55MB

Can your referral form be accessed and filled out online?

Yes

No

If your referral form can be accessed online, please include the URL (link) here:

If you are a therapist within a larger organization with multiple therapists, how can a referral source ensure the client is referred specifically to you?

Checkboxes

Option 1

Option 2