LVPCA 2013Directory Information Survey

Online Directory Update Version

The information you provide will be published in the 2013 LVPCA online directory.

NameHighest Degree Year

LastFirstM.I.

MajorInstitution

Please list the address, phone number, fax number and e-mail address that you want published.

Address

Is above address your home address [ ]or your office/work address[ ](Please check appropriate box.)

Phone #Fax #

e-mail address:

It is VERYimportant that you include your e-mail address to ensure that you receive future communications from LVPCA.

LVPCA Status:Member Affiliate Fellow Emertius(check one)

Licenses: Please check all that apply:

[ ]Psychologist (Licensed) / [ ]Counselor (Licensed) / [ ]Psychotherapist
[ ]Psychologist (Unlicensed) / [ ]Counselor (Unlicensed) / [ ]Pastoral Counselor
[ ]Social Worker (Licensed) / [ ]Affiliates
[ ]Social Worker (Unlicensed) / [ ]Other Mental Health Professional

If you are licensed as a Psychologist in PA please list your #

If licensed as a Psychologist in other states please list states & #s

If licensed in a profession other than Psychology, please list profession, states, and #s below:

Certifications: Please check all that apply:

[ ]National Health Register For / [ ]ABPP / [ ]Clinical Member, AAMFT
Health Service Providers in / [ ]Certified School Psychologist / [ ]Supervisor, AAMFT
Psychology / [ ]Certified Mental Health Counselor / [ ]National Certified Counselor
[ ]Certified Addictions Counselor
[ ]Other Board Certifications/ Diplomates

Professional setting: (please check or list in order of amount of time spent in setting)

Primary

/

Secondary

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Tertiary

/ What age groups do you treat?
Academic Institution /  /  /  / (Please check all age groups that apply.)
Private Practice /  /  /  / ____All Ages
Clinic or Agency /  /  /  / ____Early childhood(Birth to 6 yrs)
Hospital (State or General) /  /  /  / ____Middle childhood(7-12 years)
Public School /  /  /  / ____ Adolescence (13-18 years)
Private School /  /  /  / ____ Adults
Research /  /  / 
Industrial/Organizational /  /  /  / What foreign languages do you
Other:______/  /  /  / speak?
Other:______/  /  /  / ______
Other:______/  /  / 

Are you retired from active practice? [ ]Yes [ ] No

AREAS OF INTEREST: Please check a maximum of 5 of the following areas of interest which apply to you. Any checked areas in excess of 5 will not be listed.

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Act 120 and/or Act 235 Testing

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Health services consultation to business

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Addictions – Substance Abuse/Dependency

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Hypnosis

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Addictions – Other (please specify on line below)

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Impaired professionals

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Industrial/Organizational Psychology

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Adjustment disorders and relationship problems

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LGBTQ populations and/or LGBTQissues

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Adult Counseling

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Health services consultation to business

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Anxiety, somatoform, or dissociative disorders

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Hypnosis

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Behavior therapy

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Impaired professionals

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Behavioral health assessments

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Industrial/Organizational Psychology

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Bereavement

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Organizational development

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Biofeedback

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Pastoral counseling

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Brain injuries and serious physical traumas

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Personality disorders

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Brief, intensive psychotherapy

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Pet Therapy

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Career evaluations and counseling

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Physical disabilities

Child and Adolescent Counseling

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Physical health problems involving behavioral interventions

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Clinical neuropsychological assessment and intervention

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Play therapy

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Cognitive and/or cognitive-behavioral therapy

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PTSD-posttraumatic stress disorder

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Crisis intervention

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Psychosexual disorders

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Cultural Differences (please specify on line below)

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Psychoanalysis

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Psychoeducational evaluations

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Developmental disorders

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Psychological testing, Adults

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Disability determinations and worker comp evals

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Psychological testing, Children/Adolescents

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Domestic violence and/or child abuse

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Psychopharmacology

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Dually diagnosed individuals

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Schizophrenia and/or other psychoses

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Eating disorders

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Smoking cessation and/or weight loss

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Employment Testing

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Sports psychology

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Expressive therapies

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Stress and/or pain management

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Family psychotherapy and counseling

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Terminally ill (including AIDS/HIV+)

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Forensic evaluations including court ordered

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Women’s Issues

evaluationsand custody evaluations

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Other (please specify on lines below)

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Forensic interventions

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Gender issues

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Group Therapy (please specify on line below)

Are you willing to offer?

Practicum/Internship to undergraduate student ____Yes ____No

Practicum/Internship to graduate student ____Yes ____No

Supervision, Masters level ____Yes ____No

Supervision, Doctoral level____Yes ____No

Research experience to undergraduate student ____Yes ____No

Research experience to graduate student ____Yes ____No

Experience with a Psychologist for high school student ____Yes ____No

Experience with Psychologist for undergraduate student ____Yes ____No

Experience with Psychologist for graduate ____Yes ____No

Please return completed form to (include “Online Directory Form” in the subject line):

Or mail to:

Becky Reid

5205 Geissinger Road

Zionsville PA 18092