THERAPISTS’ SIGN UP FOR WI AREA DATABASE This request form is LISCENCED therapists IN GOOD STANDING, looking to become part of the database. DIOCESE OR REGION INFO* Title* Name* Email* Company* Business Address* City* State * Zip* Phone* Psychotherapy Orientation:* Problem Areas & Challenges Served (affective disorders, personality disorders, pornography, sexual issues, anger issues, addictions, etc.): Ages of clients seen* Self-pay only or Insurance or both* Family therapy offered:* yes no Individual therapy offered?* yes no Group therapy offered?* yes no Couples Therapy offered?* yes no Teletherapy/videotherapy offered?* yes no In home services offered?* yes no School visits offered?* yes no Name and city of parish or church you attend:* Name of a priest or minister reference & phone #:* Any background training in Philosophy and or Theology? Please specify.* Type of licensure* I certify that what I have entered is true and correct; and that I am an active Catholic or Christian who respects the Catholic faith and its official (Magisterial) teachings. (This is an ecumenical list, so please specify which option best applies.)* Yes, I certify the above is true and correct, and that I am a Catholic therapist who believes fully in the teachings of the Church. Yes, I certify the above is true and correct, and I am a Christian therapist who respects and supports clients coming from a Catholic faith perspective. Yes, the above is true and correct, however I am unsure about whether I can effectively help someone who has difficulties connected to their Catholic faith. Yes, I certify the above is true and correct, and I am unsure of where I stand. I just try to help people. I carry professional liability insurance:* yes no Disclaimer: Not a CPA or a JCI vetted list. Neither entity nor Dr. Simeone-DiFrancesco are responsible for the information listed as being accurate.* I understand Please explain this to me further.