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Hey, awesome therapist. Tell us about yourself and let's get you matched with your ideal clients!
Have additional questions? Call us at
714-725-9897
or send us an email at
hello@ethera.org
.
First Name
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First
Last Name
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Last
Email
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Phone
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License Type
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LMFT
AMFT
LCSW
ACSW
LPCC
APCC
LEP
Psychologist
Psychiatrist
NP
PhD
Other
License #
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Have you ever been the subject of any disciplinary action or malpractice claim?
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Yes
No
Zip code(s) of practice
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What type of services do you provide?
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Individual
Family
Art
Couples
Group
Play
Other
Untitled
Focus: What issues do you work well with and enjoy? (Select up to 10)
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Addiction
ADHD
Anxiety
Autism
Bipolar
Career/Academic Stress
Children
Chronic Health Issues
Co-dependency
Depression
Domestic Violence
Eating Disorders
Faith-Based
Financial Stress
Grief/Loss
Infertility
Insomnia
LGBTQ+
Life Transitions
Men's Issues
OCD
Parenting
Perfectionism
Perinatal/Postpartum
Personality Disorders
Racial Trauma
Racial/Cultural Identity
Relationship Issues
Self-Harm
Self-Esteem
Sex-Intimacy Issues
Substance Abuse
Teens
Trauma/PTSD
Women's Issues
Other
Other Focus
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What are your specialties?
Which of the following topics do you most enjoy exploring with your clients? (Select up to 4)
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Thought patterns
Behaviors
Relationships
Narrative
Childhood and past life experiences
Life goals
Stress and trauma
Identity
Finding meaning in life
Other
Other topics
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How would you describe your ideal client?
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Which of these best describes your therapeutic orientation? (Select up to 3)
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Attachment-based
Behavioral (CBT, DBT)
Humanistic
Psychodynamic
Solution-focused
Trauma Focused
Other
Other orientation
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Expertise: Do you have any advanced training or certifications?
How would your clients describe your therapist personality?
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As you may know, clients may have certain preferences when choosing a therapist. Please share whatever you feel comfortable sharing!
Gender
Male
Female
Transgender
Non-binary
Other
Age
24-35
36-45
46-55
56-70
71+
Ethnicity
American Indian or Alaskan Native
Asian
Black
Hispanic or Latino
Pacific Islander
White
Multi-racial
Other
Sexual Orientation
Heterosexual
LGBTQIA+
Other
Religious Background
Non-Religious
Christian/Catholic
Muslim
Buddhist
Hindu
Other
Spoken Languages
Billing Options
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Out of Pocket
Sliding Scale
Superbill
Insurance: In Network
Insurance: Out of Network
Other
What is your out of pocket rate per session?
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Sliding Scale Rates
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Insurance & Other Comments
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Session Types Offered
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In person
Online
Other
Other Session Types
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Which days and times are you available to schedule clients?
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Anything else we should know about you to help make the best match?
How did you hear about us?
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Colleague
Google
Email
Classifieds
Facebook/Instagram
Linkedin
Other
Other
Feel free to drop a link to your PsychToday profile or website
Email
This field is for validation purposes and should be left unchanged.
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