If you have any questions about the Directory application or the website, please call Annik Larsen, LCSW at 503-957-0135 or e-mail alarsen@wtpnw.org.
Name/Licensure
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- Name should appear as First, Middle, Last.
- For those with 2 last names, CAPITALIZE which name you want to be alphabetized by.
- After your name, give your Licensure/Certification (you may have more than one), e.g. ACSW, LCSW, LMFT, LPC, PhD (implying PhD in Clinical Psychology: PhD* would read "PhD in..." in the Special Skills/Training section below) etc...
- Only if you do NOT have licensure should MA, MDiv, MS, MSW etc. appear after your name.
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Office Street Address
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Suite No.
- Give street, suite number, building number or P.O. Box number
- The Post Office will reject mail that does not show a suite number where one exists so please indicate your suite number if you have one.
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City
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State
Zip+4
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- Zip Code MUST include all 9 digits (if you don't know, please look it up at www.usps.com).
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Location |
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Downtown
(west
of Willamette River, south of Burnside,
within I-405 loop) |
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North (west of N Williams, north/west of Willamette River) |
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Northwest
(north of Burnside, north/west of Willamette
River) |
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Northeast (north
of Burnside, east of Willamette River) |
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Southwest (outside
I-405 loop, south of Burnside, west of
Willamette River |
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Southeast (south
of Burnside, east of Willamette River |
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Surrounding Cities (includes Vancouver, Hood River, Wilsonville, etc.) |
- If you have more than one office, select as many locations as apply.
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Check box if your primary office is Disabled Accessible |
Phone |
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Email |
Publish in Directory?
yes
no
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Web Page |
(will be published in Directory) |
Second Office Address (if you have one) |
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Check box if you would like your Newsletter mailed to an address other than your office; please give desired address to receive the Newsletter here:
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License #(s)
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- Enter the issuing state, define the license, and give license number(s). You cannot be listed without this info.
- If you do not hold a licensure, you MUST enter your supervisor's name and credentials, and indicate your field of major study for the degree(s) shown next to your Name above.
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Years Clinical Experience |
(enter WHOLE years) |
Preferred
Areas of
Practice |
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Office Hours |
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- If you have a flat fee and not a range, enter your fee in the "Minimum" column.
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Sliding Scale |
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Insurance Reimbursement |
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Special Skills/Training
(25 words max.) |
- List appropriate SKILLS here, not areas of clinical interest (which you'll be able to list below). You might list training in specific techniques such as EMDR or hypnosis, or ancillary skills such as a foreign language, nursing degree, etc.
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Areas of Clinical Interest |
- Check the boxes in the white column for as many areas of clinical interest as apply to your practice. These will appear in our "Specialty Index" in the back of the printed WTPNW Directory as well as online.
- In the gray column, select your "Top Six" areas of clinical interest. These will appear on your individual page.
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Theoretical Orientation
(50 words max. Anything longer will be edited) |
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Check box if you want to add a photograph to your listing.
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Check box if you would like a WTPNW email address (format is first initial last name@wtpnw.org). This is useful if you want to be contacted by clients but don’t want to give out a personal email address.
- Your wtpnw email will automatically appear on your directory page.
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Comments or Questions?
(optional)
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Please proof-read your information carefully before submitting.
If you have any questions about the Directory application or the website, please contact Annik Larsen, LCSW at 503-957-0135 or alarsen@wtpnw.org
