Name
APA Number: 
First Name:             Last Name:  

Office Address

Address:

City:		State:
Zip:		Country:

                                 Specify Neighborhood or Area:   

Office Telephone:		Email:
Fax:		Web Page URL:

Second Office Address

Address2:

City2:		State2:
Zip2:		Country2:

                                   Specify Neighborhood or Area2:   

Office Telephone 2:		Email 2:
Fax 2:		Web Page URL 2:

Home Address

Home Address:

City:		State:
Zip:		Country:
Home Phone Number:

Highest Degree/year/school/major:
Post Doctoral Program/year/degree/specialty:
Licensure:
Specialty Certification/Certifying Organization:
Work Experience:
Work Experience 2:
Work Experience 3:

For the expertise list below, RANK ORDER no more than ten skills. Give rank #1 to the area in which you have the highest degree of skill. Indicate whether your expertise is in Clinical Practice (P), Consultation (C), Supervision (S), Teaching/Training/Lecturing (T), or Media (M). Fill in all that apply.

Rank 1:     Administration in Mental Health/Academic Settings ADHD/ADD Adolescent Therapy Adoption and Foster Care Adult Survivors of Childhood Sexual Abuse Affective Disorders Alcohol and Substance Abuse Alzheimer's Disease Anxiety and Phobic Disorders Assessment - Adult, Including Vocational Assessment - Child and Adolescent Behavioral Medicine Behavior Therapy Bereavement Issues Biofeedback Borderline Personality Brain Damage Brief Therapy Career Development Child Abuse/Child Sexual Abuse Child Custody Child Play Therapy Chronic Illness Chronic Pain Client-Centered Therapy Cognitive Behavioral Therapy Community Psychology/Public Policy Conduct Disorders Corporate Consulting Crisis Intervention Developmental Disability/Autism Dissociation Domestic Violence Dual Diagnosis Dying/Terminal Illness Eating Disorders EMDR Family Therapy/Parenting Feminist Therapy Forensic Psychology Gay/Lesbian/Bisexual/Relationship Issues Gender Issues Geriatric Therapy Group Therapy Health Psychology HIV/AIDS Hypnosis Impaired Professionals Impulse Disorders Industrial/Organizational Psychology Integrative/Holistic Therapy Juvenile Justice Law Enforcement Learning Disabilities Marriage/Couples Counseling Managed Care and Private Practice Issues Men's Issues Military Psychology Neuropsychology Obsessive Compulsive Disorder Physical Disabilities Poetry/Psychodrama/Art Therapies Post-Traumatic Stress Disorder Program Planning and Evaluation Psychoanalysis Psychodynamic Psychotherapy Psycho-Oncology Psychopharmacology Psychosomatic Disorder Racial/Ethnic Issues/Diversity (Specify in next section) Rational Emotive Therapy Religion and Spirituality Research/Grant Writing School Psychology Separation/Divorce/Remarriage/Divorce Mediation Severe and Persistent Mental Illness Sex Offenders Sexual Dysfunction Sleep Disorders Smoking Cessation Sports Psychology Step-Families Stress Management Transpersonal Psychology Women's Issues Workplace Issues Other (Specify in Next Section	Expertise 1:     P C S T M ,	P C S T M ,	P C S T M ,	P C S T M ,	P C S T M
Rank 2:     Administration in Mental Health/Academic Settings ADHD/ADD Adolescent Therapy Adoption and Foster Care Adult Survivors of Childhood Sexual Abuse Affective Disorders Alcohol and Substance Abuse Alzheimer's Disease Anxiety and Phobic Disorders Assessment - Adult, Including Vocational Assessment - Child and Adolescent Behavioral Medicine Behavior Therapy Bereavement Issues Biofeedback Borderline Personality Brain Damage Brief Therapy Career Development Child Abuse/Child Sexual Abuse Child Custody Child Play Therapy Chronic Illness Chronic Pain Client-Centered Therapy Cognitive Behavioral Therapy Community Psychology/Public Policy Conduct Disorders Corporate Consulting Crisis Intervention Developmental Disability/Autism Dissociation Domestic Violence Dual Diagnosis Dying/Terminal Illness Eating Disorders EMDR Family Therapy/Parenting Feminist Therapy Forensic Psychology Gay/Lesbian/Bisexual/Relationship Issues Gender Issues Geriatric Therapy Group Therapy Health Psychology HIV/AIDS Hypnosis Impaired Professionals Impulse Disorders Industrial/Organizational Psychology Integrative/Holistic Therapy Juvenile Justice Law Enforcement Learning Disabilities Marriage/Couples Counseling Managed Care and Private Practice Issues Men's Issues Military Psychology Neuropsychology Obsessive Compulsive Disorder Physical Disabilities Poetry/Psychodrama/Art Therapies Post-Traumatic Stress Disorder Program Planning and Evaluation Psychoanalysis Psychodynamic Psychotherapy Psycho-Oncology Psychopharmacology Psychosomatic Disorder Racial/Ethnic Issues/Diversity (Specify in next section) Rational Emotive Therapy Religion and Spirituality Research/Grant Writing School Psychology Separation/Divorce/Remarriage/Divorce Mediation Severe and Persistent Mental Illness Sex Offenders Sexual Dysfunction Sleep Disorders Smoking Cessation Sports Psychology Step-Families Stress Management Transpersonal Psychology Women's Issues Workplace Issues Other (Specify in Next Section	Expertise 2:     P C S T M ,	P C S T M ,	P C S T M ,	P C S T M ,	P C S T M
Rank 3:     Administration in Mental Health/Academic Settings ADHD/ADD Adolescent Therapy Adoption and Foster Care Adult Survivors of Childhood Sexual Abuse Affective Disorders Alcohol and Substance Abuse Alzheimer's Disease Anxiety and Phobic Disorders Assessment - Adult, Including Vocational Assessment - Child and Adolescent Behavioral Medicine Behavior Therapy Bereavement Issues Biofeedback Borderline Personality Brain Damage Brief Therapy Career Development Child Abuse/Child Sexual Abuse Child Custody Child Play Therapy Chronic Illness Chronic Pain Client-Centered Therapy Cognitive Behavioral Therapy Community Psychology/Public Policy Conduct Disorders Corporate Consulting Crisis Intervention Developmental Disability/Autism Dissociation Domestic Violence Dual Diagnosis Dying/Terminal Illness Eating Disorders EMDR Family Therapy/Parenting Feminist Therapy Forensic Psychology Gay/Lesbian/Bisexual/Relationship Issues Gender Issues Geriatric Therapy Group Therapy Health Psychology HIV/AIDS Hypnosis Impaired Professionals Impulse Disorders Industrial/Organizational Psychology Integrative/Holistic Therapy Juvenile Justice Law Enforcement Learning Disabilities Marriage/Couples Counseling Managed Care and Private Practice Issues Men's Issues Military Psychology Neuropsychology Obsessive Compulsive Disorder Physical Disabilities Poetry/Psychodrama/Art Therapies Post-Traumatic Stress Disorder Program Planning and Evaluation Psychoanalysis Psychodynamic Psychotherapy Psycho-Oncology Psychopharmacology Psychosomatic Disorder Racial/Ethnic Issues/Diversity (Specify in next section) Rational Emotive Therapy Religion and Spirituality Research/Grant Writing School Psychology Separation/Divorce/Remarriage/Divorce Mediation Severe and Persistent Mental Illness Sex Offenders Sexual Dysfunction Sleep Disorders Smoking Cessation Sports Psychology Step-Families Stress Management Transpersonal Psychology Women's Issues Workplace Issues Other (Specify in Next Section	Expertise 3:     P C S T M ,	P C S T M ,	P C S T M ,	P C S T M ,	P C S T M
Rank 4:     Administration in Mental Health/Academic Settings ADHD/ADD Adolescent Therapy Adoption and Foster Care Adult Survivors of Childhood Sexual Abuse Affective Disorders Alcohol and Substance Abuse Alzheimer's Disease Anxiety and Phobic Disorders Assessment - Adult, Including Vocational Assessment - Child and Adolescent Behavioral Medicine Behavior Therapy Bereavement Issues Biofeedback Borderline Personality Brain Damage Brief Therapy Career Development Child Abuse/Child Sexual Abuse Child Custody Child Play Therapy Chronic Illness Chronic Pain Client-Centered Therapy Cognitive Behavioral Therapy Community Psychology/Public Policy Conduct Disorders Corporate Consulting Crisis Intervention Developmental Disability/Autism Dissociation Domestic Violence Dual Diagnosis Dying/Terminal Illness Eating Disorders EMDR Family Therapy/Parenting Feminist Therapy Forensic Psychology Gay/Lesbian/Bisexual/Relationship Issues Gender Issues Geriatric Therapy Group Therapy Health Psychology HIV/AIDS Hypnosis Impaired Professionals Impulse Disorders Industrial/Organizational Psychology Integrative/Holistic Therapy Juvenile Justice Law Enforcement Learning Disabilities Marriage/Couples Counseling Managed Care and Private Practice Issues Men's Issues Military Psychology Neuropsychology Obsessive Compulsive Disorder Physical Disabilities Poetry/Psychodrama/Art Therapies Post-Traumatic Stress Disorder Program Planning and Evaluation Psychoanalysis Psychodynamic Psychotherapy Psycho-Oncology Psychopharmacology Psychosomatic Disorder Racial/Ethnic Issues/Diversity (Specify in next section) Rational Emotive Therapy Religion and Spirituality Research/Grant Writing School Psychology Separation/Divorce/Remarriage/Divorce Mediation Severe and Persistent Mental Illness Sex Offenders Sexual Dysfunction Sleep Disorders Smoking Cessation Sports Psychology Step-Families Stress Management Transpersonal Psychology Women's Issues Workplace Issues Other (Specify in Next Section	Expertise 4:     P C S T M ,	P C S T M ,	P C S T M ,	P C S T M ,	P C S T M
Rank 5:     Administration in Mental Health/Academic Settings ADHD/ADD Adolescent Therapy Adoption and Foster Care Adult Survivors of Childhood Sexual Abuse Affective Disorders Alcohol and Substance Abuse Alzheimer's Disease Anxiety and Phobic Disorders Assessment - Adult, Including Vocational Assessment - Child and Adolescent Behavioral Medicine Behavior Therapy Bereavement Issues Biofeedback Borderline Personality Brain Damage Brief Therapy Career Development Child Abuse/Child Sexual Abuse Child Custody Child Play Therapy Chronic Illness Chronic Pain Client-Centered Therapy Cognitive Behavioral Therapy Community Psychology/Public Policy Conduct Disorders Corporate Consulting Crisis Intervention Developmental Disability/Autism Dissociation Domestic Violence Dual Diagnosis Dying/Terminal Illness Eating Disorders EMDR Family Therapy/Parenting Feminist Therapy Forensic Psychology Gay/Lesbian/Bisexual/Relationship Issues Gender Issues Geriatric Therapy Group Therapy Health Psychology HIV/AIDS Hypnosis Impaired Professionals Impulse Disorders Industrial/Organizational Psychology Integrative/Holistic Therapy Juvenile Justice Law Enforcement Learning Disabilities Marriage/Couples Counseling Managed Care and Private Practice Issues Men's Issues Military Psychology Neuropsychology Obsessive Compulsive Disorder Physical Disabilities Poetry/Psychodrama/Art Therapies Post-Traumatic Stress Disorder Program Planning and Evaluation Psychoanalysis Psychodynamic Psychotherapy Psycho-Oncology Psychopharmacology Psychosomatic Disorder Racial/Ethnic Issues/Diversity (Specify in next section) Rational Emotive Therapy Religion and Spirituality Research/Grant Writing School Psychology Separation/Divorce/Remarriage/Divorce Mediation Severe and Persistent Mental Illness Sex Offenders Sexual Dysfunction Sleep Disorders Smoking Cessation Sports Psychology Step-Families Stress Management Transpersonal Psychology Women's Issues Workplace Issues Other (Specify in Next Section	Expertise 5:     P C S T M ,	P C S T M ,	P C S T M ,	P C S T M ,	P C S T M
Rank 6:     Administration in Mental Health/Academic Settings ADHD/ADD Adolescent Therapy Adoption and Foster Care Adult Survivors of Childhood Sexual Abuse Affective Disorders Alcohol and Substance Abuse Alzheimer's Disease Anxiety and Phobic Disorders Assessment - Adult, Including Vocational Assessment - Child and Adolescent Behavioral Medicine Behavior Therapy Bereavement Issues Biofeedback Borderline Personality Brain Damage Brief Therapy Career Development Child Abuse/Child Sexual Abuse Child Custody Child Play Therapy Chronic Illness Chronic Pain Client-Centered Therapy Cognitive Behavioral Therapy Community Psychology/Public Policy Conduct Disorders Corporate Consulting Crisis Intervention Developmental Disability/Autism Dissociation Domestic Violence Dual Diagnosis Dying/Terminal Illness Eating Disorders EMDR Family Therapy/Parenting Feminist Therapy Forensic Psychology Gay/Lesbian/Bisexual/Relationship Issues Gender Issues Geriatric Therapy Group Therapy Health Psychology HIV/AIDS Hypnosis Impaired Professionals Impulse Disorders Industrial/Organizational Psychology Integrative/Holistic Therapy Juvenile Justice Law Enforcement Learning Disabilities Marriage/Couples Counseling Managed Care and Private Practice Issues Men's Issues Military Psychology Neuropsychology Obsessive Compulsive Disorder Physical Disabilities Poetry/Psychodrama/Art Therapies Post-Traumatic Stress Disorder Program Planning and Evaluation Psychoanalysis Psychodynamic Psychotherapy Psycho-Oncology Psychopharmacology Psychosomatic Disorder Racial/Ethnic Issues/Diversity (Specify in next section) Rational Emotive Therapy Religion and Spirituality Research/Grant Writing School Psychology Separation/Divorce/Remarriage/Divorce Mediation Severe and Persistent Mental Illness Sex Offenders Sexual Dysfunction Sleep Disorders Smoking Cessation Sports Psychology Step-Families Stress Management Transpersonal Psychology Women's Issues Workplace Issues Other (Specify in Next Section	Expertise 6:     P C S T M ,	P C S T M ,	P C S T M ,	P C S T M ,	P C S T M
Rank 7:     Administration in Mental Health/Academic Settings ADHD/ADD Adolescent Therapy Adoption and Foster Care Adult Survivors of Childhood Sexual Abuse Affective Disorders Alcohol and Substance Abuse Alzheimer's Disease Anxiety and Phobic Disorders Assessment - Adult, Including Vocational Assessment - Child and Adolescent Behavioral Medicine Behavior Therapy Bereavement Issues Biofeedback Borderline Personality Brain Damage Brief Therapy Career Development Child Abuse/Child Sexual Abuse Child Custody Child Play Therapy Chronic Illness Chronic Pain Client-Centered Therapy Cognitive Behavioral Therapy Community Psychology/Public Policy Conduct Disorders Corporate Consulting Crisis Intervention Developmental Disability/Autism Dissociation Domestic Violence Dual Diagnosis Dying/Terminal Illness Eating Disorders EMDR Family Therapy/Parenting Feminist Therapy Forensic Psychology Gay/Lesbian/Bisexual/Relationship Issues Gender Issues Geriatric Therapy Group Therapy Health Psychology HIV/AIDS Hypnosis Impaired Professionals Impulse Disorders Industrial/Organizational Psychology Integrative/Holistic Therapy Juvenile Justice Law Enforcement Learning Disabilities Marriage/Couples Counseling Managed Care and Private Practice Issues Men's Issues Military Psychology Neuropsychology Obsessive Compulsive Disorder Physical Disabilities Poetry/Psychodrama/Art Therapies Post-Traumatic Stress Disorder Program Planning and Evaluation Psychoanalysis Psychodynamic Psychotherapy Psycho-Oncology Psychopharmacology Psychosomatic Disorder Racial/Ethnic Issues/Diversity (Specify in next section) Rational Emotive Therapy Religion and Spirituality Research/Grant Writing School Psychology Separation/Divorce/Remarriage/Divorce Mediation Severe and Persistent Mental Illness Sex Offenders Sexual Dysfunction Sleep Disorders Smoking Cessation Sports Psychology Step-Families Stress Management Transpersonal Psychology Women's Issues Workplace Issues Other (Specify in Next Section	Expertise 7:     P C S T M ,	P C S T M ,	P C S T M ,	P C S T M ,	P C S T M
Rank 8:     Administration in Mental Health/Academic Settings ADHD/ADD Adolescent Therapy Adoption and Foster Care Adult Survivors of Childhood Sexual Abuse Affective Disorders Alcohol and Substance Abuse Alzheimer's Disease Anxiety and Phobic Disorders Assessment - Adult, Including Vocational Assessment - Child and Adolescent Behavioral Medicine Behavior Therapy Bereavement Issues Biofeedback Borderline Personality Brain Damage Brief Therapy Career Development Child Abuse/Child Sexual Abuse Child Custody Child Play Therapy Chronic Illness Chronic Pain Client-Centered Therapy Cognitive Behavioral Therapy Community Psychology/Public Policy Conduct Disorders Corporate Consulting Crisis Intervention Developmental Disability/Autism Dissociation Domestic Violence Dual Diagnosis Dying/Terminal Illness Eating Disorders EMDR Family Therapy/Parenting Feminist Therapy Forensic Psychology Gay/Lesbian/Bisexual/Relationship Issues Gender Issues Geriatric Therapy Group Therapy Health Psychology HIV/AIDS Hypnosis Impaired Professionals Impulse Disorders Industrial/Organizational Psychology Integrative/Holistic Therapy Juvenile Justice Law Enforcement Learning Disabilities Marriage/Couples Counseling Managed Care and Private Practice Issues Men's Issues Military Psychology Neuropsychology Obsessive Compulsive Disorder Physical Disabilities Poetry/Psychodrama/Art Therapies Post-Traumatic Stress Disorder Program Planning and Evaluation Psychoanalysis Psychodynamic Psychotherapy Psycho-Oncology Psychopharmacology Psychosomatic Disorder Racial/Ethnic Issues/Diversity (Specify in next section) Rational Emotive Therapy Religion and Spirituality Research/Grant Writing School Psychology Separation/Divorce/Remarriage/Divorce Mediation Severe and Persistent Mental Illness Sex Offenders Sexual Dysfunction Sleep Disorders Smoking Cessation Sports Psychology Step-Families Stress Management Transpersonal Psychology Women's Issues Workplace Issues Other (Specify in Next Section	Expertise 8:     P C S T M ,	P C S T M ,	P C S T M ,	P C S T M ,	P C S T M
Rank 9:     Administration in Mental Health/Academic Settings ADHD/ADD Adolescent Therapy Adoption and Foster Care Adult Survivors of Childhood Sexual Abuse Affective Disorders Alcohol and Substance Abuse Alzheimer's Disease Anxiety and Phobic Disorders Assessment - Adult, Including Vocational Assessment - Child and Adolescent Behavioral Medicine Behavior Therapy Bereavement Issues Biofeedback Borderline Personality Brain Damage Brief Therapy Career Development Child Abuse/Child Sexual Abuse Child Custody Child Play Therapy Chronic Illness Chronic Pain Client-Centered Therapy Cognitive Behavioral Therapy Community Psychology/Public Policy Conduct Disorders Corporate Consulting Crisis Intervention Developmental Disability/Autism Dissociation Domestic Violence Dual Diagnosis Dying/Terminal Illness Eating Disorders EMDR Family Therapy/Parenting Feminist Therapy Forensic Psychology Gay/Lesbian/Bisexual/Relationship Issues Gender Issues Geriatric Therapy Group Therapy Health Psychology HIV/AIDS Hypnosis Impaired Professionals Impulse Disorders Industrial/Organizational Psychology Integrative/Holistic Therapy Juvenile Justice Law Enforcement Learning Disabilities Marriage/Couples Counseling Managed Care and Private Practice Issues Men's Issues Military Psychology Neuropsychology Obsessive Compulsive Disorder Physical Disabilities Poetry/Psychodrama/Art Therapies Post-Traumatic Stress Disorder Program Planning and Evaluation Psychoanalysis Psychodynamic Psychotherapy Psycho-Oncology Psychopharmacology Psychosomatic Disorder Racial/Ethnic Issues/Diversity (Specify in next section) Rational Emotive Therapy Religion and Spirituality Research/Grant Writing School Psychology Separation/Divorce/Remarriage/Divorce Mediation Severe and Persistent Mental Illness Sex Offenders Sexual Dysfunction Sleep Disorders Smoking Cessation Sports Psychology Step-Families Stress Management Transpersonal Psychology Women's Issues Workplace Issues Other (Specify in Next Section	Expertise 9:     P C S T M ,	P C S T M ,	P C S T M ,	P C S T M ,	P C S T M
Rank 10:   Administration in Mental Health/Academic Settings ADHD/ADD Adolescent Therapy Adoption and Foster Care Adult Survivors of Childhood Sexual Abuse Affective Disorders Alcohol and Substance Abuse Alzheimer's Disease Anxiety and Phobic Disorders Assessment - Adult, Including Vocational Assessment - Child and Adolescent Behavioral Medicine Behavior Therapy Bereavement Issues Biofeedback Borderline Personality Brain Damage Brief Therapy Career Development Child Abuse/Child Sexual Abuse Child Custody Child Play Therapy Chronic Illness Chronic Pain Client-Centered Therapy Cognitive Behavioral Therapy Community Psychology/Public Policy Conduct Disorders Corporate Consulting Crisis Intervention Developmental Disability/Autism Dissociation Domestic Violence Dual Diagnosis Dying/Terminal Illness Eating Disorders EMDR Family Therapy/Parenting Feminist Therapy Forensic Psychology Gay/Lesbian/Bisexual/Relationship Issues Gender Issues Geriatric Therapy Group Therapy Health Psychology HIV/AIDS Hypnosis Impaired Professionals Impulse Disorders Industrial/Organizational Psychology Integrative/Holistic Therapy Juvenile Justice Law Enforcement Learning Disabilities Marriage/Couples Counseling Managed Care and Private Practice Issues Men's Issues Military Psychology Neuropsychology Obsessive Compulsive Disorder Physical Disabilities Poetry/Psychodrama/Art Therapies Post-Traumatic Stress Disorder Program Planning and Evaluation Psychoanalysis Psychodynamic Psychotherapy Psycho-Oncology Psychopharmacology Psychosomatic Disorder Racial/Ethnic Issues/Diversity (Specify in next section) Rational Emotive Therapy Religion and Spirituality Research/Grant Writing School Psychology Separation/Divorce/Remarriage/Divorce Mediation Severe and Persistent Mental Illness Sex Offenders Sexual Dysfunction Sleep Disorders Smoking Cessation Sports Psychology Step-Families Stress Management Transpersonal Psychology Women's Issues Workplace Issues Other (Specify in Next Section	Expertise 10:   P C S T M ,	P C S T M ,	P C S T M ,	P C S T M ,	P C S T M

Racial/Ethnic Issues/Diversity (Other):