International Resources Recommendations

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* 1. Resource Contact Info

Business or Organization:

Website:

Business Address:

City:

State / Province:

Country:

Postal Code:

Business Phone Number:

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* 2. Contact Person for Organization / Provider

Contact Name:

Contact Email:

Contact Phone Number:

Position / role of contact:

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* 3. What Type of Mental Health Resource is this? (Choose all that apply)

Counseling Service

Treatment Center (In-patient, Detox, etc.)

Referral Service

Crisis Line

Mental Health Peer Support Line

Other (please specify)

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* 4. What does this mental health resource offer? (Choose all that apply)

Individual Counseling

Group Counseling

New Clients

Licensed Counselors

Intensive Out-Patient Programs

Residential Treatment Centers

Aftercare

Support Groups

Detox

Crisis Center

Other (please specify)

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* 5. Is this resource a Non-profit organization?

Yes

Waiting on non-profit status approval

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* 6. Please indicate any counseling specialties. (While most centers are equipped to deal with many of these areas, please select those which this resource specifically specializes in and regularly treats)

Depression

Addiction

Self-injury

Anxiety

Eating Disorders

Trauma

Abuse

Loss/ Grief

Other (please specify)

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* 7. Resource Rates - please select any of these offered by this resource:

Sliding Scale Fees (Rates are based on income)

Expertise based rates (depending on the expertise of the counselor)

Reduced Rates (for master level / intern counselors)

Financial assistance or scholarship for clients

Student discount

Accepts Insurance

Other (please specify)

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* 1. Resource Contact Info

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* 2. Contact Person for Organization / Provider

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* 3. What Type of Mental Health Resource is this? (Choose all that apply)

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* 4. What does this mental health resource offer? (Choose all that apply)

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* 5. Is this resource a Non-profit organization?

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* 6. Please indicate any counseling specialties. (While most centers are equipped to deal with many of these areas, please select those which this resource specifically specializes in and regularly treats)

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* 7. Resource Rates - please select any of these offered by this resource:

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* 8. Any additional information: