Clinical Areas of Expertise Form for Mental Health Care Providers

Contact Information

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* 1. Full Name:

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* 2. Title:

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* 3. Degree(s) and License(s) held:

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* 4. Clinic name (if any):

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* 5. Health Care System (if any):

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* 6. Address:

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* 7. Phone:

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* 8. Email address:

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* 9. Website:

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* 10. In your own words, how would you describe your practice?