Therapist Social Club
Membership Form
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Name: *
Professional Title *
Phone Number (personal): *
Phone Number (professional):
Email: *
Website:
Tehudat Zehut (if applicable):
Birthday: *
MM
/
DD
/
YYYY
Aliyah Date (if applicable):
MM
/
DD
/
YYYY
Where do you live in Israel? (city/neighborhood) *
What is your home country? *
Languages spoken (conversationally): *
Languages spoken (professionally, by order of preference): *
Are you currently offering services? *
Required
If you are not currently offering services, are you planning to in the future? Please elaborate on any relevant information.
What therapeutic approach/technique do you use in your practice? *
Required
What are your ideal age demographics? *
Required
Do you prefer to work with a specific gender? *
Required
If you could choose your ideal clients for your expertise, what are FIVE client groups that you would prefer to work with? (please be mindful to pick no more than five) *
Required
Do you work with insurance or offer sliding scale? *
Required
What are your hopes for the Therapist Social Club? *
What can you provide to our community? *
What professional development trainings are you interested in for the future? *
Do you feel as though you know the mental health resources available for international therapists located in TLV? *
Not at all
Very much so
Do you feel as though you are confident in your ability to refer people to other therapists, specialists, and mental health professionals in TLV? *
Not at all
Very much so
We want our members to be connected, and so we're creating a small, easily digestible database with our mini-introductions. Give us your elevator pitch (2-5 sentences)! *
Is there any other information that you would like to share with us?
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