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If you have a treatment center that treats clients who have experienced psychological trauma, childhood abuse, or dissociation, the Sidran Institute would like to list your services. To be included in our Treatment Centers Directory, please complete the questionnaire below. There is no charge for inclusion, and we thank you for the work that you do.
If you do not have a forms-capable browser, please e-mail us at forms@sidran.org or print out a PDF version, fill it out, and fax it to us at 410-560-0134. Otherwise, please fill out the form online and submit it to us.
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(*) = required field |
| * Institution name : |
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| * Street Address : |
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| * City : |
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| * State/Province : |
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| * Country : |
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| * Zip/Postal Code : |
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| * Phone : |
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| Extension : |
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| * Fax : |
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| * E-mail : |
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| * Website : |
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| * Intake/Contact Person : |
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| * Clinical Director : |
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| Name of trauma program (if different from the name of the institution above) : |
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| * Year program began operation : |
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| * Is this institution/program accredited? : |
Yes
No
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| If yes, please give name of the accrediting agency : |
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| * Populations served : |
Children
Adolescents
Adults
Males only
Females only
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| * Specializations : |
Post Traumatic Stress Disorder
Dissociative Disorders
Eating Disorders
Males only
Self-Injury
Borderline Personality Disorder
Sleep Disorders
Depressive Disorders
Anxiety Disorders
Substance Abuse/Dual Diagnosis
Sexual Orientation/Identity Issues
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| Other relevant specialties : |
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| * Philosophical Orientation (e.g. spiritual/religious) : |
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| Services and Capacity |
| * Inpatient/Residential : |
Yes
No
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| What is the capacity? : |
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| What is the ratio of staff to clients? : |
Staff :
Client :
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| Please provide a description, admission criteria, and other information a prospective client would need to know : |
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| * Emergency Shelter : |
Yes
No
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| What is the capacity? : |
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| What is the ratio of staff to clients? : |
Staff :
Client :
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| Please provide a description, admission criteria, and other information a prospective client would need to know : |
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| * Extended Care : |
Yes
No
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| What is the capacity? : |
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| What is the ratio of staff to clients? : |
Staff :
Client :
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| Please provide a description, admission criteria, and other information a prospective client would need to know : |
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| * Transitional Living : |
Yes
No
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| What is the capacity? : |
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| What is the ratio of staff to clients? : |
Staff :
Client :
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| Please provide a description, admission criteria, and other information a prospective client would need to know : |
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| * Halfway House : |
Yes
No
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| What is the capacity? : |
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| What is the ratio of staff to clients? : |
Staff :
Client :
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| Please provide a description, admission criteria, and other information a prospective client would need to know : |
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| * Intensive Outpatient : |
Yes
No
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| What is the capacity? : |
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| What is the ratio of staff to clients? : |
Staff :
Client :
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| Please provide a description, admission criteria, and other information a prospective client would need to know : |
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| * Outpatient/Walk-in Counseling/Therapy : |
Yes
No
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| What is the capacity? : |
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| What is the ratio of staff to clients? : |
Staff :
Client :
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| Please provide a description, admission criteria, and other information a prospective client would need to know : |
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| * School-Based Program : |
Yes
No
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| What is the capacity? : |
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| What is the ratio of staff to clients? : |
Staff :
Client :
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| Please provide a description, admission criteria, and other information a prospective client would need to know : |
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| Therapy |
| * How many therapists are in your program? : |
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| * What adjunctive therapies does your program offer? : |
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| * Do you run therapy groups? : |
Yes
No
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| If yes, please describe : |
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| * Do you sponsor peer-run support groups? : |
Yes
No
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| If yes, please describe : |
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| * Briefly state your Center's treatment philosophy. What issues does your program focus on and how do you treat them? : |
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| Describe the medical services available at your facility : |
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| Institutional Information |
| * Is your program affiliated with a hospital or medical center? : |
Yes
No
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| If yes, please name the institution and describe the relationship : |
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| * What types of insurance do you accept? : |
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| Does your Center/Program provide |
| Financial assistance? : |
Yes
No
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| Sliding Fee Scale? : |
Yes
No
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| Payment Plans? : |
Yes
No
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