Leek Therapy: Matching Therapists to Client Profiles

Email *

First Name *

Last Name *

Demographics

Please rate your preference for the following, and indicate 5 for most preferable, and 0 for least preferable

Adult Women

0

1

2

3

4

5

Adult Men

0

1

2

3

4

5

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:

Please rate the following based on your preference or clinical strength

Locations I offer Sessions:

Telehealth/Secure Therapy by Video (anywhere in MA)

In Person in Yarmouth Port

In Person in Bourne

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

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