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Ai Attachment Informed Application

This application is for mental health professionals interested in becoming Ai Attachment Informed for their existing work with clients.

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Section 1

Professional Information

Question 2 of 28

Name

Question 3 of 28

Date

Question 4 of 28

Email

Question 5 of 28

Business Address

Question 6 of 28

License(s) (include all, ie: LPC, MD, LMFT, Psychologist, LCSW, etc).

Question 7 of 28

License Number(s)

Question 8 of 28

State(s) of Licensure

Question 9 of 28

Years in Practice

Question 10 of 28

Board Certifications (if applicable)

Section 2

Practice Information

Question 12 of 28

Areas of Specialty and Additional Certifications or Trainings

Question 13 of 28

Current Practice Setting

A

Private Practice (Solo)

B

Private Practice (Group)

C

Community Mental Health

D

Hospital/Medical Center

E

School or University Counseling Center

F

EAP

G

Other

Question 14 of 28

Services Offered

A

Individual- Adults

B

Individual- Adolescents

C

Individual- Children

D

Couples

E

Family

F

Group

G

Psychological Assessment

H

Other

Question 15 of 28

Treatment Modalities/Approaches (ie: CBT, Narrative, Family Systems, etc)

Question 16 of 28

Telehealth Services

A

Currently Provide Telehealth

B

Willing to Provide Telehealth

C

In-person Only

Section 3

Insurance and Payment

Question 18 of 28

Do you currently take insurance or private pay only?

Section 4

Professional Standing

Question 20 of 28

Have you ever had any disciplinary action taken against your license?

Question 21 of 28

Are you currently under investigation by any licensing boards?

Section 5

Ai Attachment Informed Interest

Question 23 of 28

How did you hear about the Ai Attachment Informed approach?

Question 24 of 28

What interests you about the Ai Attachment Informed approach?

Question 25 of 28

Are you interested in volunteering your time to support therapist awareness of the Ai Attachment Informed approach?

A

No thanks, but excited to be here!

B

1-3 hours per week

C

1-3 hours per month

D

More!

Question 26 of 28

Any additional comments or questions?

Question 27 of 28

By writing my full name below, I attest that the information I have provided is true.

Thank You!

We will be in touch with you soon!

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