Word - Lehigh Valley Psychological and Counseling Association
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LVPCA 2014 Directory Information Survey Online Directory Update Version The information you provide will be published in the 2014-15 LVPCA online directory. Name Highest Degree Last First Year Middle Major Institution Please list the address, phone number, fax number and e-mail address that you want published. Address Is above address your home address or your office/work address Phone # Fax # (Please check appropriate box.) Website: e-mail address: It is VERY important that you include your e-mail address to ensure that you receive future communications from LVPCA. LVPCA Status: Member Affiliate Fellow Emertius (check one) Professional Status: Please check all that apply: [ ]Psychologist (Licensed) [ ]Psychologist (Unlicensed) [ ]Social Worker (Licensed) [ ]Social Worker (Unlicensed) [ ]Counselor (Licensed) [ ]Counselor (Unlicensed) [ ] Marriage & Family Therapist (Lic.) [ ]Marriage & Family Therapist (Unlic.) [ ]Psychotherapist [ ]Pastoral Counselor [ ]Other Mental Health Professional Specify: If you are licensed as a Psychologist in PA please list your # If licensed as a Psychologist in other states please list states & #s If licensed in a profession other than Psychology, please list profession, states, and #s below: Certifications: Please check all that apply: [ ]National Health Register For [ ]ABPP Health Service Providers in [ ]Certified School Psychologist Psychology [ ]Certified Mental Health Counselor [ ]Certified Addictions Counselor [ ]Other Board Certifications/ Diplomates [ ]Clinical Member, AAMFT [ ]Supervisor, AAMFT [ ]National Certified Counselor Professional setting: (please check according to amount of time spent in setting) Primary Secondary Tertiary Academic Institution What age groups do you treat? Private Practice ____All Ages Clinic or Agency ____Early childhood (Birth to 6 yrs) Hospital (State or General) ____Middle childhood (7-12 years) Public School ____ Adolescence (13-18 years) Private School ____ Adults (19-64 years) Research ____ Adults (65+ years) Industrial/Organizational What foreign languages do you Other:__________________ speak? Other:__________________ __________________________ Other:__________________ Are you retired from active practice? (Please check all age groups that apply.) Yes No AREAS OF INTEREST: Below is a list of common specialties. While this list is not exhaustive, it allows us to group clinicians according to specialty population/treatment. Please check a maximum of 5 of the following areas of interest which apply to you and feel free to add additional areas under “other”. Please note that checked areas in excess of 5 may not be listed in the directory due to space limitations. __ __ __ Act 120 and/or Act 235 Testing Addictions – Substance Abuse/Dependency Addictions – Other (please specify on line below) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Adjustment disorders and relationship problems Adult psychotherapy Anxiety, somatoform, or dissociative disorders Behavior therapy Behavioral health assessments Bereavement Biofeedback Brain injuries and serious physical traumas Brief, intensive psychotherapy Career evaluations and counseling Child and Adolescent psychotherapy Clinical neuropsychological assessment and intervention Cognitive and/or cognitive-behavioral therapy Couples therapy Crisis intervention Cultural Differences (please specify on line below) __ __ __ __ __ __ __ __ __ Developmental disorders Disability determinations and worker comp evals Domestic violence and/or child abuse Dually diagnosed individuals Eating disorders Employment Testing Expressive therapies Family psychotherapy Forensic evaluations including court-ordered evaluations and custody evaluations Forensic interventions Gender issues Group Therapy (please specify groups on line below) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Health services consultation to business Hypnosis Impaired professionals Industrial/Organizational Psychology LGBTQ populations and/or LGBTQ issues Health services consultation to business Hypnosis Impaired professionals Industrial/Organizational Psychology Organizational development Pastoral counseling Personality disorders Pet Therapy Physical disabilities Physical health problems involving behavioral interventions Play therapy PTSD-posttraumatic stress disorder Psychosexual disorders Psychoanalysis Psychoeducational evaluations Psychological testing, Adults Psychological testing, Children/Adolescents Psychopharmacology Schizophrenia and/or other psychoses Smoking cessation and/or weight loss Sports psychology Stress and/or pain management Terminally ill (including AIDS/HIV+) Women’s Issues Other (please specify on lines below) Are you willing to offer? Practicum/Internship to undergraduate students ____Yes ____No Practicum/Internship to graduate students ____Yes ____No Supervision, Masters level ____Yes ____No Supervision, Doctoral level ____Yes ____No Research experience to undergraduate student ____Yes ____No Research experience to graduate student ____Yes ____No Experience with a Psychologist for high school students ____Yes ____No Experience with Psychologist for undergraduate students ____Yes ____No Experience with Psychologist for graduate students ____Yes ____No Please return completed form to: draboyoun@gmail.com subject line) Or mail to: 07/2014 Darren Aboyoun, Ph.D. LLC 101 Larry Holmes Dr, Ste 200 Easton PA 18042 (Please include “Online Directory Form” in the
