Aspire Pre-Interview Questionnaire

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50% of survey complete.

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* 1. What is your name?

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* 2. What is your current Utah license to practice Mental Health Therapy?

CMHC

LCSW

LMFT

Psychologist

Provisionally Licensed as ACMHC, CSW/MSW, AMFT

Fully Licensed in another state, but not yet licensed in Utah

Other (please specify)

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* 3. Which populations are you highly skilled treating? (select up to 5 options)

Adults

Adolescent (12-18)

Children (7-11)

Children (4-6)

Children (0-3)

Elderly (65+)

Marriage Therapy

Family Therapy

Group Therapy

Other (please specify)

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* 4. Rate your skill level or familiarity with each therapeutic approach:

	I am not familiar with this style	I have some knowledge of this style	I am building skill in this style	I use this style and am proficient in its use	I am an expert in this therapeutic style
Cognitive Behavioral Therapy (CBT)	Cognitive Behavioral Therapy (CBT) I am not familiar with this style	Cognitive Behavioral Therapy (CBT) I have some knowledge of this style	Cognitive Behavioral Therapy (CBT) I am building skill in this style	Cognitive Behavioral Therapy (CBT) I use this style and am proficient in its use	Cognitive Behavioral Therapy (CBT) I am an expert in this therapeutic style
Couples Therapy (Pre-Marital)	Couples Therapy (Pre-Marital) I am not familiar with this style	Couples Therapy (Pre-Marital) I have some knowledge of this style	Couples Therapy (Pre-Marital) I am building skill in this style	Couples Therapy (Pre-Marital) I use this style and am proficient in its use	Couples Therapy (Pre-Marital) I am an expert in this therapeutic style
Dialectical Behavior Therapy (DBT)	Dialectical Behavior Therapy (DBT) I am not familiar with this style	Dialectical Behavior Therapy (DBT) I have some knowledge of this style	Dialectical Behavior Therapy (DBT) I am building skill in this style	Dialectical Behavior Therapy (DBT) I use this style and am proficient in its use	Dialectical Behavior Therapy (DBT) I am an expert in this therapeutic style
Eye Movement Desensitization and Reprocessing (EMDR)	Eye Movement Desensitization and Reprocessing (EMDR) I am not familiar with this style	Eye Movement Desensitization and Reprocessing (EMDR) I have some knowledge of this style	Eye Movement Desensitization and Reprocessing (EMDR) I am building skill in this style	Eye Movement Desensitization and Reprocessing (EMDR) I use this style and am proficient in its use	Eye Movement Desensitization and Reprocessing (EMDR) I am an expert in this therapeutic style
Emotionally Focused Therapy (EFT)	Emotionally Focused Therapy (EFT) I am not familiar with this style	Emotionally Focused Therapy (EFT) I have some knowledge of this style	Emotionally Focused Therapy (EFT) I am building skill in this style	Emotionally Focused Therapy (EFT) I use this style and am proficient in its use	Emotionally Focused Therapy (EFT) I am an expert in this therapeutic style
Family Systems	Family Systems I am not familiar with this style	Family Systems I have some knowledge of this style	Family Systems I am building skill in this style	Family Systems I use this style and am proficient in its use	Family Systems I am an expert in this therapeutic style
Hypnosis	Hypnosis I am not familiar with this style	Hypnosis I have some knowledge of this style	Hypnosis I am building skill in this style	Hypnosis I use this style and am proficient in its use	Hypnosis I am an expert in this therapeutic style
Mindfulness Based Therapy	Mindfulness Based Therapy I am not familiar with this style	Mindfulness Based Therapy I have some knowledge of this style	Mindfulness Based Therapy I am building skill in this style	Mindfulness Based Therapy I use this style and am proficient in its use	Mindfulness Based Therapy I am an expert in this therapeutic style
Narrative Therapy	Narrative Therapy I am not familiar with this style	Narrative Therapy I have some knowledge of this style	Narrative Therapy I am building skill in this style	Narrative Therapy I use this style and am proficient in its use	Narrative Therapy I am an expert in this therapeutic style
Parent Child Interaction Therapy (PCIT)	Parent Child Interaction Therapy (PCIT) I am not familiar with this style	Parent Child Interaction Therapy (PCIT) I have some knowledge of this style	Parent Child Interaction Therapy (PCIT) I am building skill in this style	Parent Child Interaction Therapy (PCIT) I use this style and am proficient in its use	Parent Child Interaction Therapy (PCIT) I am an expert in this therapeutic style
Play Therapy	Play Therapy I am not familiar with this style	Play Therapy I have some knowledge of this style	Play Therapy I am building skill in this style	Play Therapy I use this style and am proficient in its use	Play Therapy I am an expert in this therapeutic style
Psychoanalysis	Psychoanalysis I am not familiar with this style	Psychoanalysis I have some knowledge of this style	Psychoanalysis I am building skill in this style	Psychoanalysis I use this style and am proficient in its use	Psychoanalysis I am an expert in this therapeutic style
Rational Emotive Behavior Therapy (REBT)	Rational Emotive Behavior Therapy (REBT) I am not familiar with this style	Rational Emotive Behavior Therapy (REBT) I have some knowledge of this style	Rational Emotive Behavior Therapy (REBT) I am building skill in this style	Rational Emotive Behavior Therapy (REBT) I use this style and am proficient in its use	Rational Emotive Behavior Therapy (REBT) I am an expert in this therapeutic style
Reality Therapy	Reality Therapy I am not familiar with this style	Reality Therapy I have some knowledge of this style	Reality Therapy I am building skill in this style	Reality Therapy I use this style and am proficient in its use	Reality Therapy I am an expert in this therapeutic style
Solution Focused Therapy	Solution Focused Therapy I am not familiar with this style	Solution Focused Therapy I have some knowledge of this style	Solution Focused Therapy I am building skill in this style	Solution Focused Therapy I use this style and am proficient in its use	Solution Focused Therapy I am an expert in this therapeutic style
Trauma-Focused CBT	Trauma-Focused CBT I am not familiar with this style	Trauma-Focused CBT I have some knowledge of this style	Trauma-Focused CBT I am building skill in this style	Trauma-Focused CBT I use this style and am proficient in its use	Trauma-Focused CBT I am an expert in this therapeutic style

Other (please specify)

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* 5. Mark all issues you feel confident treating (Yes or No):

	Yes	No
ADD/ADHD	ADD/ADHD Yes	ADD/ADHD No
Addiction (Gambling)	Addiction (Gambling) Yes	Addiction (Gambling) No
Addiction (Internet)	Addiction (Internet) Yes	Addiction (Internet) No
Addiction (Video Game)	Addiction (Video Game) Yes	Addiction (Video Game) No
Addiction (Substance)	Addiction (Substance) Yes	Addiction (Substance) No
Addiction (Sexual)	Addiction (Sexual) Yes	Addiction (Sexual) No
Adjustment Disorder	Adjustment Disorder Yes	Adjustment Disorder No
Adoption Issues	Adoption Issues Yes	Adoption Issues No
Affective Disorders	Affective Disorders Yes	Affective Disorders No
Alzheimer's	Alzheimer's Yes	Alzheimer's No
Anger Management	Anger Management Yes	Anger Management No
Anxiety	Anxiety Yes	Anxiety No
Asperger's Syndrome	Asperger's Syndrome Yes	Asperger's Syndrome No
Attachment Issues	Attachment Issues Yes	Attachment Issues No
Autism Spectrum Disorders	Autism Spectrum Disorders Yes	Autism Spectrum Disorders No
Behavior Disorders	Behavior Disorders Yes	Behavior Disorders No
Bereavement Issues	Bereavement Issues Yes	Bereavement Issues No
Bipolar	Bipolar Yes	Bipolar No
Blended Family Issues	Blended Family Issues Yes	Blended Family Issues No
Bullying Issues	Bullying Issues Yes	Bullying Issues No
Career Issues / Downsizing	Career Issues / Downsizing Yes	Career Issues / Downsizing No
Caregiver Burnout	Caregiver Burnout Yes	Caregiver Burnout No
Chemical Dependency	Chemical Dependency Yes	Chemical Dependency No
Child Abuse	Child Abuse Yes	Child Abuse No
Chronic Illness	Chronic Illness Yes	Chronic Illness No
Chronic Pain	Chronic Pain Yes	Chronic Pain No
Codependency	Codependency Yes	Codependency No
Conduct Disorder	Conduct Disorder Yes	Conduct Disorder No
Crisis Intervention	Crisis Intervention Yes	Crisis Intervention No
Delusional Disorder	Delusional Disorder Yes	Delusional Disorder No
Dementia	Dementia Yes	Dementia No
Depression (Major)	Depression (Major) Yes	Depression (Major) No
Depression (Postpartum)	Depression (Postpartum) Yes	Depression (Postpartum) No
Dissociative Disorder	Dissociative Disorder Yes	Dissociative Disorder No
Divorce	Divorce Yes	Divorce No
Eating Disorders	Eating Disorders Yes	Eating Disorders No
Eliminating Disorders	Eliminating Disorders Yes	Eliminating Disorders No
Factitious Disorder	Factitious Disorder Yes	Factitious Disorder No
Family Violence (Victim)	Family Violence (Victim) Yes	Family Violence (Victim) No
Family Violence (Perpetrator)	Family Violence (Perpetrator) Yes	Family Violence (Perpetrator) No
Grief/Loss	Grief/Loss Yes	Grief/Loss No
Impulse Control Disorders	Impulse Control Disorders Yes	Impulse Control Disorders No
Infertility	Infertility Yes	Infertility No
Learning Disabilities	Learning Disabilities Yes	Learning Disabilities No
Long/Short Term Disability	Long/Short Term Disability Yes	Long/Short Term Disability No
Marriage	Marriage Yes	Marriage No
Masturbation	Masturbation Yes	Masturbation No
Medical Psychology	Medical Psychology Yes	Medical Psychology No
Men's Issues	Men's Issues Yes	Men's Issues No
Mental Retardation	Mental Retardation Yes	Mental Retardation No
Motivation Issues	Motivation Issues Yes	Motivation Issues No
Multiple Personality Disorder (MPD/DID)	Multiple Personality Disorder (MPD/DID) Yes	Multiple Personality Disorder (MPD/DID) No
Occupational Adjustment	Occupational Adjustment Yes	Occupational Adjustment No
Obsessive Compulsive Disorder (OCD)	Obsessive Compulsive Disorder (OCD) Yes	Obsessive Compulsive Disorder (OCD) No
Panic Disorders	Panic Disorders Yes	Panic Disorders No
Parenting Issues	Parenting Issues Yes	Parenting Issues No
Perfectionism	Perfectionism Yes	Perfectionism No
Personality Disorder - Borderline	Personality Disorder - Borderline Yes	Personality Disorder - Borderline No
Personality Disorders - Narcissism	Personality Disorders - Narcissism Yes	Personality Disorders - Narcissism No
Personality Disorders (other)	Personality Disorders (other) Yes	Personality Disorders (other) No
Pervasive Developmental Disorder (PDD)	Pervasive Developmental Disorder (PDD) Yes	Pervasive Developmental Disorder (PDD) No
Phobias	Phobias Yes	Phobias No
Pornography Addiction	Pornography Addiction Yes	Pornography Addiction No
Post Incest Disorder	Post Incest Disorder Yes	Post Incest Disorder No
Psychoses	Psychoses Yes	Psychoses No
Psychosomatic Disorder	Psychosomatic Disorder Yes	Psychosomatic Disorder No
Post Traumatic Stress Disorder (PTSD)	Post Traumatic Stress Disorder (PTSD) Yes	Post Traumatic Stress Disorder (PTSD) No
PTSD (Combat)	PTSD (Combat) Yes	PTSD (Combat) No
Reactive Attachment Disorder (RAD)	Reactive Attachment Disorder (RAD) Yes	Reactive Attachment Disorder (RAD) No
Relaxation	Relaxation Yes	Relaxation No
Schizophrenia	Schizophrenia Yes	Schizophrenia No
School/Academic Performance	School/Academic Performance Yes	School/Academic Performance No
Scrupulosity	Scrupulosity Yes	Scrupulosity No
Self-Harm	Self-Harm Yes	Self-Harm No
Self-Worth Issues	Self-Worth Issues Yes	Self-Worth Issues No
Sensory Integration Disorder	Sensory Integration Disorder Yes	Sensory Integration Disorder No
Separation (Relationship)	Separation (Relationship) Yes	Separation (Relationship) No
Separation Anxiety	Separation Anxiety Yes	Separation Anxiety No
Sexual Abuse (Victim)	Sexual Abuse (Victim) Yes	Sexual Abuse (Victim) No
Sexual Abuse (Perpetrator)	Sexual Abuse (Perpetrator) Yes	Sexual Abuse (Perpetrator) No
Sexual Disorders	Sexual Disorders Yes	Sexual Disorders No
Sexual Dysfunction	Sexual Dysfunction Yes	Sexual Dysfunction No
Sexual Identity Issues	Sexual Identity Issues Yes	Sexual Identity Issues No
Sexual Reactivity in Children	Sexual Reactivity in Children Yes	Sexual Reactivity in Children No
Sleep Disorders	Sleep Disorders Yes	Sleep Disorders No
Smoking Cessation	Smoking Cessation Yes	Smoking Cessation No
Somatoform Disorder	Somatoform Disorder Yes	Somatoform Disorder No
Spiritual Issues	Spiritual Issues Yes	Spiritual Issues No
Step Families	Step Families Yes	Step Families No
Stress Management	Stress Management Yes	Stress Management No
Substance Abuse	Substance Abuse Yes	Substance Abuse No
Substance Related Disorder	Substance Related Disorder Yes	Substance Related Disorder No
Suicidal Ideation	Suicidal Ideation Yes	Suicidal Ideation No
Terminal Illness	Terminal Illness Yes	Terminal Illness No
Tic Disorders	Tic Disorders Yes	Tic Disorders No
Tourette's Syndrome	Tourette's Syndrome Yes	Tourette's Syndrome No
Transvestic Fetishism	Transvestic Fetishism Yes	Transvestic Fetishism No
Trichotillomania	Trichotillomania Yes	Trichotillomania No
Urgent Stress	Urgent Stress Yes	Urgent Stress No
Weight Loss	Weight Loss Yes	Weight Loss No
Women's Issues	Women's Issues Yes	Women's Issues No

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* 6. What do you feel is a reasonable charge for a 53-60 minute session of therapy in a private practice setting? (Mark up to 2 options)

Over $150

$120-$150

$90 to $120

Less than $90

Sliding Scale Fee

As much as the market can bear provided that I provide excellent care

As little as I can as long as it is enough for me to make a living

Other (please specify)

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* 7. Describe any entrepreneurial experience you have had in the past.

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* 8. How comfortable are you with collecting payment directly from a client in a private practice setting?

I would prefer that someone else collect payments

I think I could learn to do so, but will likely always feel somewhat awkward doing so

I believe that I could learn to feel at ease doing so

I would feel completely at ease doing so

I would prefer that someone else collect payments

I think I could learn to do so, but will likely always feel somewhat awkward doing so

I believe that I could learn to feel at ease doing so

I would feel completely at ease doing so

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* 9. In your opinion how important is each of the following to the delivery of clinical care and customer service in a private practice setting?

	Not important	Somewhat important	Important	Very important	Extremely important
Low Pricing	Low Pricing Not important	Low Pricing Somewhat important	Low Pricing Important	Low Pricing Very important	Low Pricing Extremely important
High Pricing	High Pricing Not important	High Pricing Somewhat important	High Pricing Important	High Pricing Very important	High Pricing Extremely important
Reasonable Pricing	Reasonable Pricing Not important	Reasonable Pricing Somewhat important	Reasonable Pricing Important	Reasonable Pricing Very important	Reasonable Pricing Extremely important
Punctuality	Punctuality Not important	Punctuality Somewhat important	Punctuality Important	Punctuality Very important	Punctuality Extremely important
Clinical skill in my area(s) of expertise	Clinical skill in my area(s) of expertise Not important	Clinical skill in my area(s) of expertise Somewhat important	Clinical skill in my area(s) of expertise Important	Clinical skill in my area(s) of expertise Very important	Clinical skill in my area(s) of expertise Extremely important
Well rounded skills over a broad spectrum of issues	Well rounded skills over a broad spectrum of issues Not important	Well rounded skills over a broad spectrum of issues Somewhat important	Well rounded skills over a broad spectrum of issues Important	Well rounded skills over a broad spectrum of issues Very important	Well rounded skills over a broad spectrum of issues Extremely important
Professionalism	Professionalism Not important	Professionalism Somewhat important	Professionalism Important	Professionalism Very important	Professionalism Extremely important
Response time in returning calls or emails	Response time in returning calls or emails Not important	Response time in returning calls or emails Somewhat important	Response time in returning calls or emails Important	Response time in returning calls or emails Very important	Response time in returning calls or emails Extremely important
Setting clear boundaries	Setting clear boundaries Not important	Setting clear boundaries Somewhat important	Setting clear boundaries Important	Setting clear boundaries Very important	Setting clear boundaries Extremely important
Asking for help when you need it	Asking for help when you need it Not important	Asking for help when you need it Somewhat important	Asking for help when you need it Important	Asking for help when you need it Very important	Asking for help when you need it Extremely important
Going the extra mile	Going the extra mile Not important	Going the extra mile Somewhat important	Going the extra mile Important	Going the extra mile Very important	Going the extra mile Extremely important
Ability of clinician to say "No"	Ability of clinician to say "No" Not important	Ability of clinician to say "No" Somewhat important	Ability of clinician to say "No" Important	Ability of clinician to say "No" Very important	Ability of clinician to say "No" Extremely important
Willingness to refer out to others in the client's best interest	Willingness to refer out to others in the client's best interest Not important	Willingness to refer out to others in the client's best interest Somewhat important	Willingness to refer out to others in the client's best interest Important	Willingness to refer out to others in the client's best interest Very important	Willingness to refer out to others in the client's best interest Extremely important
Personal financial management skills	Personal financial management skills Not important	Personal financial management skills Somewhat important	Personal financial management skills Important	Personal financial management skills Very important	Personal financial management skills Extremely important
Business financial management skills	Business financial management skills Not important	Business financial management skills Somewhat important	Business financial management skills Important	Business financial management skills Very important	Business financial management skills Extremely important
Ability to include spirituality in therapy (even if different from my own)	Ability to include spirituality in therapy (even if different from my own) Not important	Ability to include spirituality in therapy (even if different from my own) Somewhat important	Ability to include spirituality in therapy (even if different from my own) Important	Ability to include spirituality in therapy (even if different from my own) Very important	Ability to include spirituality in therapy (even if different from my own) Extremely important
Reading social cues	Reading social cues Not important	Reading social cues Somewhat important	Reading social cues Important	Reading social cues Very important	Reading social cues Extremely important
Coordinating client care with parents, doctors, clergy, etc	Coordinating client care with parents, doctors, clergy, etc Not important	Coordinating client care with parents, doctors, clergy, etc Somewhat important	Coordinating client care with parents, doctors, clergy, etc Important	Coordinating client care with parents, doctors, clergy, etc Very important	Coordinating client care with parents, doctors, clergy, etc Extremely important
Personal moral & life decisions	Personal moral & life decisions Not important	Personal moral & life decisions Somewhat important	Personal moral & life decisions Important	Personal moral & life decisions Very important	Personal moral & life decisions Extremely important
Boldness in difficult interactions	Boldness in difficult interactions Not important	Boldness in difficult interactions Somewhat important	Boldness in difficult interactions Important	Boldness in difficult interactions Very important	Boldness in difficult interactions Extremely important
Personable nature of therapist	Personable nature of therapist Not important	Personable nature of therapist Somewhat important	Personable nature of therapist Important	Personable nature of therapist Very important	Personable nature of therapist Extremely important
Nice office and furnishings	Nice office and furnishings Not important	Nice office and furnishings Somewhat important	Nice office and furnishings Important	Nice office and furnishings Very important	Nice office and furnishings Extremely important
Client focused customer service practices	Client focused customer service practices Not important	Client focused customer service practices Somewhat important	Client focused customer service practices Important	Client focused customer service practices Very important	Client focused customer service practices Extremely important

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* 10. Select the option that you feel is the most effective time to collect payment from a client in a private practice setting?

Send invoices on a monthly basis for all services received that month

Send a bill in the mail following all sessions

Before a session begins

At the end of a session

Have someone else do collection of payments to separate money issues from the therapeutic relationship

Other (please specify)

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* 11. Scenario:

You realize you have two separate clients who have shown up to the same appointment time and are both in the waiting area. Each is anticipating to be seen in this next session. You check your schedule and see that one client has arrived at the right time (1:00 PM) but on the wrong day (Tuesday instead of Thursday). How would you handle this situation?

Place approaches in the order that you agree with (most {1} to least {5}):

Apologize profusely for the mix-up and offer a discount to the person who is willing to reschedule

Ask the clients in the waiting room who needs the session most and reschedule with the other

Let the mistaken client know of their correct appointment time, praise their commitment to be present for appointments and send them off with a small gift card for a treat

I would prefer that the receptionist handle it

Inform the mistaken client of their appointment time and ask them to return at that time

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* 12. Please mark how others would describe you in each of the following areas:

	Weak	Average	Actively Building	Strong	Excellent
Clinical Skill	Clinical Skill Weak	Clinical Skill Average	Clinical Skill Actively Building	Clinical Skill Strong	Clinical Skill Excellent
Customer Service	Customer Service Weak	Customer Service Average	Customer Service Actively Building	Customer Service Strong	Customer Service Excellent
Personable Nature	Personable Nature Weak	Personable Nature Average	Personable Nature Actively Building	Personable Nature Strong	Personable Nature Excellent
Punctuality	Punctuality Weak	Punctuality Average	Punctuality Actively Building	Punctuality Strong	Punctuality Excellent
Consideration of Others	Consideration of Others Weak	Consideration of Others Average	Consideration of Others Actively Building	Consideration of Others Strong	Consideration of Others Excellent
Honesty	Honesty Weak	Honesty Average	Honesty Actively Building	Honesty Strong	Honesty Excellent

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* 13. What would you enjoy most about working in a private practice setting? (mark the top 3 reasons)

Autonomy in treatment decisions

Doing something different than most people in the field

Increased earning potential

Ability to focus on desired treatment populations

Self determination

Scheduling freedom

Status of being self employed

Other (please specify)

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* 14. The following are all important aspects of private practice. Rank in order of how strongly you possess each of these qualities (from greatest {1} to least {5}):

Business sense/experience

Clinical skill

Tolerance to risk

Customer service

Interpersonal skills

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* 15. The idea of being the one who is ultimately responsible for my income and for providing benefits for my family causes me to feel:

Terror, I have never been responsible for this before and I don't know if I can

Timid, it seems a bit risky

Unsure, I hope that I will be able to do so

Positive, I believe that if I put effort into my business that it will pay off

Invigorated, I can financially do as well or better by taking this responsibility on myself

Terror, I have never been responsible for this before and I don't know if I can

Timid, it seems a bit risky

Unsure, I hope that I will be able to do so

Positive, I believe that if I put effort into my business that it will pay off

Invigorated, I can financially do as well or better by taking this responsibility on myself

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* 16. What sets you apart from other clinicians?

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* 17. What are your thoughts about the involvement of spirituality in the process of therapy?

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* 18. Which of the following challenges of working in a private practice setting would be difficult for you? (mark top 3 challenging factors)

Not having a guaranteed, fixed income

Being accountable to make final decisions with regard to treatment and business decisions

Letting go of habits and mentality established in agency setting

Not having someone else to direct me in what I should do

Being responsible for things that others would do for me in an agency work setting

Other (please specify)

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* 19. Do you have three former/present clients who would be willing to contact us and relate why they have confidence in you as a therapist?

Yes

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* 20. Are you interested in accepting insurances?

Yes

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* 21. Which insurances are you interested in taking? (select all that apply)

Aetna

Altius/MHNet

BCBS (Blue Cross Blue Shield)

Cigna

CHIP

DMBA (Deseret Mutual Benefits Association)

EMI (Educators Mutual)

Meritain

Medicaid

Medicare

PEHP

Select Health

Tricare

United Healthcare

University of Utah Health Network

Value Options

WISE Network

Any

Employee Assistance Programs (EAP)

Only high paying insurances

Mid level reimbursing insurances

Low level reimbursing insurances

Those insurances which serve underprivileged populations

Those insurances which serve public employees

Those insurances serving the military and their dependents

Those insurance which serve private industry

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* 22. Would you feel comfortable working with LDS bishops to coordinate treatment for members of their ward?

Yes

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* 23. Please describe what you believe are the major differences between practicing therapy in an agency vs a private practice setting.

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Use this picture to answer the question below.

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* 24. Using the map of the parking lot (above) please indicate which colored section of parking spots you would prefer to park in when seeing clients at Aspire:

Purple (1)

Blue (4)

Orange (3)

Red (6)

Green (2)

Yellow (5)

Other (please specify)