Psychiatric Referral Database

Practice Availability & Services Offered

MAPP has a referral service and we'd like you participate if you wish. In order to make this as efficient as possible, please complete this survey so we can match the best person for the referral. This is a confidential survey and only MAPP's Executive Director will use this information.

Question Title

* 1. Demographic Information

Name

Company

Business Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Business Email Address

Business Phone Number

Question Title

* 2. Are you employed by a hospital or large practice?

Yes

Name of Hospital/Practice

Question Title

* 3. Are you still practicing?

I am retired (you do not need to complete the rest of the questions)

I am semi-retired

Yes, I'm still practicing

Question Title

* 4. Do you have openings in your practice?

Yes

Question Title

* 5. What is the best way to contact you to make an appointment?

Phone

E-mail

Website

Webite address

Question Title

* 6. What populations do you treat?

Adolescent

Adult

Child

Geriatric

LGBTQ

Veterans

Question Title

* 7. What are your clinical speciality areas?

Acceptance & Commitment Therapy

Adult ADHD

Anger Management

Anxiety / panic disorders

Behavioral problems

Bipolar Disorder

Child abuse & neglect

Clinical focus for firefighters, law enforcement, EMS

Coping with chronic illness / chronic pain

Couples Counseling

Depression

Developmental Issues

Domestic violence

Eating disorders / obesity

Grief / loss

Interpersonal, work, health and family stress

Obsessive compulsive disorder

Personality Disorders

Psychodynamic Psychotherapy

Psychosis with Schizophrenia

Sexual health

Sleep disorders

Spiritual / religious / faith-based or pastoral

Stress

Substance Use Disorders

Suicide

Trauma / PTSD

Other (please specify)

Question Title

* 8. Please list any type of insurance you accept:

Aetna

Anthem

Blue Cross / Blue Shield

Ceridian

Cigna

Harvard Pilgrim

Humana

Maine Community Health Options

Maine Medical Center PHO

MaineCare

Medicaid

Medicare

Meridian

Multiplan

Optum

Tricare

Tufts

United Health

None

If you do not accept insurance, do you offer a sliding fee scale?

Question Title

* 9. Do you offer telehealth appointments?

Yes

Psychiatric Referral Database

Practice Availability & Services Offered

Question Title

* 1. Demographic Information

Question Title

* 2. Are you employed by a hospital or large practice?

Question Title

* 3. Are you still practicing?

Question Title

* 4. Do you have openings in your practice?

Question Title

* 5. What is the best way to contact you to make an appointment?

Question Title

* 6. What populations do you treat?

Question Title

* 7. What are your clinical speciality areas?

Question Title

* 8. Please list any type of insurance you accept:

Question Title

* 9. Do you offer telehealth appointments?

Question Title

* 10. Is there anything else you'd like to add?