Mental Health Directory Application Survey

Kalamazoo Community Mental Health with the assistance of Gryphon Place is creating a searchable data base of mental health providers in Kalamazoo County. In order to be included in this voluntary directory you will need to completely and accurately fill out this form. All license numbers will be verified through the Michigan Department of Licensing and Regulatory Affairs (LARA) website http://www7.dleg.state.mi.us/free/.

If you have any problems or questions please contact Sarah Mann at Gryphon Place either by email, smann@gryphon.org, or by telephone at 269-381-1510, extension 222.

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1. Demographic Information

Demographic Information Name of Practitioner:
Agency:
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Email Address:
Main Phone Number:

2. Fax Phone Number

3. Toll Free Number

Toll Free Number Toll Free Number:

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4. License Number.

License Number.

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5. Mark all focus areas for practice.

Mark all focus areas for practice. Addiction ADD/ADHD Anger Anxiety Disorders Autism Spectrum Cognitive Disorders Developmental Disorders	Depression Eating Disorders Family Related Issues Gender Identity Grief and Loss Personality Disorders Physical Abuse	Sexual Abuse Sleep Disorders Substance Abuse Suicide Violence
Other (please specify)

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6. Population Served. Mark all that apply

Population Served. Mark all that apply Adolescents

Adults

Children

Families

Foster Care

Spanish Speaking

Veterans

Other (please specify)

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7. Type of therapy/services offered. Mark all that apply.

Type of therapy/services offered. Mark all that apply. Assessment

Case Management

Diagnostic Testing

Family

Group

Holistic

Individual

Play

Other (please specify)

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8. Type of payment options offered: Mark all that apply.

Type of payment options offered: Mark all that apply. Medicare

Medicaid

Blue Cross Blue Shield

Priority

United Health Care

Sliding Fee

Other (please specify)

9. A brief description of the provided services.

A brief description of the provided services.

10. Person to contact for future updates if different from practitioner

Person to contact for future updates if different from practitioner Name:
Email Address:

11. Form Completed By:

Form Completed By: Name:
Email Address:
Phone Number: