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International Resources Recommendations
1.
Resource Contact Info
Business or Organization:
Website:
Business Address:
City:
State / Province:
Country:
Postal Code:
Business Phone Number:
2.
Contact Person for Organization / Provider
Contact Name:
Contact Email:
Contact Phone Number:
Position / role of contact:
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)
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)
5.
Is this resource a Non-profit organization?
Yes
No
Waiting on non-profit status approval
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)
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)
8.
Any additional information:
