Leek Therapy: Matching Therapists to Client Profiles

Email *

First Name *

Last Name *

Demographics

Please rate your preference for the following client demographics, 5 for most preferable, 0 for least preferable:

Adult Women

0

1

2

3

4

5

Adult Men

0

1

2

3

4

5

Children/Preteens: 5 to 13

0

1

2

3

4

5

Teens

0

1

2

3

4

5

Young Adults: 18 to 25

0

1

2

3

4

5

Adults: 26 to 40

0

1

2

3

4

5

Adults: 41 to 60

0

1

2

3

4

5

Adults: 61 and Older

0

1

2

3

4

5

Billing and Insurance

I am credentialed with the following:

Self Pay

Blue Cross Blue Shield

Tufts

Harvard Pilgrim

Optum

MassHealth

Others

Location and Clinical Preferences:

Location(s) I offer sessions:

Telehealth/Secure Therapy by Video (anywhere in MA)

In Person in West Yarmouth

In Person in Bourne

In Person in Boston

Please rate the following based on your preference or

clinical strength:

Depression

0

1

2

3

4

5

Anxiety

0

1

2

3

4

5

Personal Relationships:

0

1

2

3

4

5

ADHD

0

1

2

3

4

5

Identity

0

1

2

3

4

5

Personal Wellbeing/Improvement:

0

1

2

3

4

5

Substance Use or Addiction:

0

1

2

3

4

5

Eating Disorders:

0

1

2

3

4

5

Recent Discharge from Hospital:

0

1

2

3

4

5

Autism

0

1

2

3

4

5

LGBTQ

0

1

2

3

4

5

PTSD

0

1

2

3

4

5

Conduct/Behavioral Issues:

0

1

2

3

4

5

Availability:

Please describe your availability to see clients:

My ideal number of average weekly sessions is:

4

5

6

7

8

9

10

20

25

30

32

34

36

38

40

Other

Specify Other Number of Average Availability

General Availability for Sessions

Week Days 8AM to 3PM

Week Days 3PM to 6PM

Week Days 6PM to 8PM

Weekends