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Provider Survey

This survey is designed for you to share with us as many details as possible about your behavioral health practice so we may accurately connect you with potential clients who are a good fit for your business.
1.Please enter your name and the physical address of the location where you will be providing services.
2.Please enter your treatment area(s) of focus.  Select all that apply.
3.What is your gender?
4.What are your pronouns?
5.What languages do you provide services in besides English? 
6.What modes of therapy do you use?  Check all that apply.
7.What age groups do you serve in your practice?  Check all that apply.
8.Are you accepting new clients? 
9.What insurances do you take for payment?  Check all that apply.
10.Where do you provide services?  Check all that apply.
11.Which conditions do you treat? Check all that apply.
12.What types of therapy do you provide?  Check all that apply.
13.What are your credentials in Oregon?  Check all that apply.
14.Which of the following services would you be interested in exploring? Check all that apply.