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If you are a clinician treating clients who have experienced psychological trauma, childhood abuse, or dissociation, the Sidran Institute would like to list your services. To be included in our Therapist 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 tracy.howard@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.

Contact Information
(*) = required field
* First Name :
Middle Name :
* Last Name :
* Degree :
* Title :
Company :
* Street Address :
Second Address (if applicable) :
* City :
* State/Province :
Country :
* Zip/Postal Code :
* Phone :
Extension :
Alternate Phone :
Fax :
* E-mail (for administrative use only) :
Public E-mail Address (optional) :
Website :
I give permission for Sidran to share the public e-mail address listed above with potential clients : Yes  No
* Have you previously submitted your information? : Yes  No
* Gender : Male  Female
       Training and Credentials
* Please list degrees, certifications, and other training :
* Please list memberships in professional organizations :
* Have you ever been censured by any professional licensing body? : Yes  No
If Yes, please specify dates and circumstances :
* Do you use hypnosis? : Yes  No
If Yes, please specify for what purposes :
* Do you use EMDR? : Yes  No
* Do you use "energy therapies" or other complementary treatment approaches? : Yes  No
If yes, please describe :
* Do you have advanced training specifically related to the treatment of trauma? : Yes  No
* Do you have advanced training specifically related to the treatment of dissociative disorders? : Yes  No

Do you provide:  
* Individual Therapy? : Yes  No
* Group Therapy? : Yes  No
* Family Therapy? : Yes  No
* Couples Therapy? : Yes  No
* Support Groups (peer-run)? : Yes  No
* Support Groups (therapist-run)? : Yes  No
* Are you affiliated with a treatment center that provides inpatient services? : Yes  No
* Are you affiliated with a psychiatrist that provides pharmaceutical support? : Yes  No
* Populations served : Children
Special populations served : Gay/Lesbian
Combat Veterans
Ritual Abuse Victims
Offenders (Adult)
Offenders (Juvenile)
If Other, please describe :
* Is your office accessible to people with physical disabilities? : Yes  No
* Are you fluent in any languages other than English (including ASL for the hearing impaired)? : Yes  No
If so, please specify :
Do you treat:  
* Post Traumatic Stress Disorder? : Yes  No
* Dissociative Disorders? : Yes  No
* Eating Disorders? : Yes  No
* Self-Injury? : Yes  No
* Borderline Personality Disorder? : Yes  No
* Sleep Disorders? : Yes  No
* Depressive Disorders? : Yes  No
* Anxiety Disorders? : Yes  No
* Substance Abuse/Dual Diagnosis? : Yes  No
* Sexual Orientation/Identity Issues? : Yes  No
Other relevant specialties? :
       Insurance Information
Do you accept :  
* Private Insurance? : Yes  No
* Medicare? : Yes  No
* State Assistance? : Yes  No
Do you have :  
* Negotiable Fees : Yes  No
* A sliding fee scale? : Yes  No
* Do you accept fee only (no insurance)? : Yes  No
Please specify which insurance plans you accept :
        * Therapist Statement
Write something about yourself or your practice that potential clients would benefit from knowing: this could include your approach, philosophy, background, techniques, or other information. This statement will be shared with prospective clients.:
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"We help people understand, recover from, and treat trauma and dissociation"