Leek Therapy: Matching Therapists to Client Profiles

Email *

First Name *

Last Name *

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

The following information will be used to help you build your ideal caseload. Please use the rating system below to complete this form.

0 = I do not work with this client demographic/condition (exclude completely from referrals)
1 = Not ideal, but open to considering
2–3 = Comfortable with this demographic/condition
4–5 = Ideal clients and conditions

Client Demographics

Adult Women

0

1

2

3

4

5

Adult Men

0

1

2

3

4

5

Teens

0

1

2

3

4

5

Young Adults: 18 to 25

0

1

2

3

4

5

Children/Preteens: 5 to 13

0

1

2

3

4

5

Adults: 41 to 60

0

1

2

3

4

5

Adults: 26 to 40

0

1

2

3

4

5

Adults: 61 and Older

0

1

2

3

4

5

Clinical Preferences:

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

Gender/ Sexual 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:

General Availability for Sessions

Weekdays 8 AM to 3 PM

Weekdays 3 PM to 6 PM

Weekdays 6 PM to 8 PM

Weekends