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We are seeking to improve our community referral database to make the best referrals possible. We frequently refer individuals for several reasons.

• Longer-term or more intensive therapy for Notre Dame students.
• Referrals for spouses, children, or other family members of students, faculty, or staff.
• Providers from other communities seeking local referral recommendations.

If you are interested in receiving referrals from us, please fill out the questionnaire below.

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* 1. Contact Information

***Please note: e-mail address will NOT be given to ND students, but used by our office to contact you/update this survey annually.

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* 2. Gender:

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* 3. Please indicate your race/ethnicity.

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* 4. License

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* 5. Highest Relevant Degree:

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* 6. Degree Information

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* 7. Other relevant degrees, credentials, certifications, or trainings:

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* 8. Number of years in practice:

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* 9. How many individual therapy clients do you see in an average week?

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* 10. What are your areas of clinical expertise?

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* 11. Membership in professional organizations.

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* 12. Please briefly describe your theoretical/therapeutic approach. (If you use a more eclectic or integrated approach, please indicate the main theories or therapeutic approaches you draw from).

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* 13. Have you ever been sanctioned or are you currently under review by any professional ethics body, university disciplinary committee, state licensing board or other regulatory body or ever had a license revoked or suspended?

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* 14. Please estimate what proportion of your practice (in terms of percentage) involves working with the following age groups.

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* 15. Please estimate the number of Notre Dame students you have worked with in your practice.

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* 16. Please estimate the number of college students you have worked with in your practice.

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* 17. Do you offer weekend appointments?

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* 18. Do you offer evening appointments?

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* 19. Please list any languages you speak other than English and indicate whether you are proficient enough to conduct therapy in this language.

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* 20. Do you bill insurance? (Check all that apply)

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* 21. Do you offer a Sliding Fee Scale?

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* 22. What is your regular fee for a clinical hour (i.e., 45-50 min. therapy appointment)?

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* 23. Please indicate the statement that best describes your after-hours crisis coverage.

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* 24. If you offer group therapy, what kinds of groups do you routinely conduct?

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* 25. Please rate your skill and interest in working with the following issues:

  1 Don't work with these issues 2 Little 3 Proficient 4 Strong 5 Area of Specialty
Abuse (physical/sexual, etc.)
ADHD
Anger management
Anxiety disorders
Autism –spectrum disorders.
Bipolar spectrum disorders
Chemical Dependency/Substance Abuse
Childhood Behavioral Disorders (e.g., conduct disorder, oppositional-defiant disorder)
Compulsive Gambling
Developmental Disabilities
Depression
Discrimination/Harassment
Dissociative Disorders
Domestic Violence
Eating Disorders
Forensic Issues
Gay/Lesbian/Bisexual/Questioning Issues
Grief/Bereavement
Learning Disabilities
Internet Addiction/Pornography Addiction
Medical Illness Disease Management
Multicultural Issues
Obsessive Compulsive Disorder
Organic Disorders
Pain Management
Paraphilias
Personality Disorders
Sexual Assault/Rape
Sexual Dysfunction
Sleep Disorders
Somatoform Disorders
Suicidality/Self-Harm
Thought Disorders
Transgender Issues
Trauma

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* 26. Please indicate if your practice involves a significant amount of the following services.

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* 27. Please estimate the total number of individual clients you have worked with over the past five years from the following populations:

  None Under 5 6 to 10 11 to 20 21 or more
African-American/Black
American Indian or Alaskan Native
Asian-American/Asian
Caucasian/White
Hispanic / Latino/a
Native Hawaiian or Pacific Islander
Multiracial
Other Racial/Ethnic Population

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* 28. Other than yourself, please list the names of 5 therapists in the local community to whom you would feel most comfortable referring a family member or close friend.

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* 29. Other than yourself, who would be your top therapy referral choice for the following issues/populations:

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* 30. Please list the names of 3 psychiatrists in the local community to whom you would feel most comfortable referring a family member or close friend.

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* 31. Would you be interested in presenting to our Predoctoral Psychology Interns (Training Seminars) or Clinical Staff (Brown Bag Lunch Seminars) on any topics related to clinical issues, diagnoses, particular client populations, diversity issues, etc.? If so, please indicate any topics on which you would feel comfortable presenting.

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