Clinic Directory

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The Counseling Collective

Location: 16 Taumutu Road

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Personal Details

First Name *

Last Name *

Email *

Languages *

Select the language(s) you can use to communicate with your clients

Profile Image *

Please supply a headshot image that we will use for your Professional Directory profile entry

Devin_Brown

File name: Devin_Brown.jpg

File size: 5 KB

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Country *

What country are you licensed in?

State Licensure

If in the US, which state(s) are you licensed in?

Name of Practice

The name of your private practice or where you provide your services from

Member's Website

Your professional website

Business Address (City-State)

Please only enter as City, State or City, Country. Please DO NOT put your full address here.

Business Address (City-State) #2

Use this field if you need at add a second address you operate from. Please only enter as City, State or City, Country. Please DO NOT put your full address here.

Business Address (Full)

Only enter if you are doing in person sessions and wish to advertise your clinic address.

Business Address (Full) #2

Only enter if you are doing in person sessions and wish to advertise your clinic address. This field is used if you have a second clinic address

Phone Number

Select the correct country then enter your phone number. The format will change update as you enter your number (Note for New Zealand - the zero will be taken off the front of your number to display it in correct international number format. ie 022 123 4567 will become +64 22 123 4567)

Social Media

Facebook

Your Facebook page (Business or Personal)

Instagram

Your Instagram page (Business or Personal)

Twitter

Your Twitter page (Business or Personal)

Your LinkedIn page

YouTube

Your YouTube channel (Business or Personal)

Professional Details

Qualification #1

Please gives us the name of your first qualification ,the institution you received it from and the year you graduated. For example: Bachelors of Psychology at Stanford University - 1998. This information will be displayed on your directory profile. If you do not want it displayed, please do not provide.

Qualification #2

Same instructions as the first qualification item above.

Qualification #3

Same instructions as the first qualification item above.

Qualification #4

Same instructions as the first qualification item above.

Annual Practicing Certificates *

Please supply the Licensure or Annual Practicing Certificate numbers for any of your current registrations. Please specify which board you belong to without using acronyms.

	Enter your certificate details here
1
1

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Price per Session

Enter your normal session price here. You will be able to set up different prices in your booking profile.

Office Hours

Give us your normal office hours. You will be able to change these in your booking profile.

Clinical Details

Introduction

Please give an introduction about yourself.

About Me

Copy/paste from membership application

Clinical Approach

Funding Streams Available Other

If other, please specify the funding stream and provide a website with details for ACFB to review.

Sliding Scale

Do you offer sliding scale price to clients ?

Forms of Support *

What forms of support do you offer?

Online
In Person
Group
SMS

Professional Membership #1

Professional Membership #2

Professional Membership #3

Additional Images or Video

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Image #3

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Image #4

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Image #6

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Image #7

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Image #8

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Image #9

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YouTube Video #1

Link to one of your YouTube videos

YouTube Video #2

Link to one of your YouTube videos

YouTube Video #3

Link to one of your YouTube videos

YouTube Video #4

Link to one of your YouTube videos

Certification and Trainings

Recent Trainings Attended Text

Recent Trainings Attended Text #2

Recent Trainings Attended Text #3

Recent Publications Link

Recent Publications Text

Recent Publications Link #2

Recent Publications Text #2

Recent Publications Link #3

Recent Publications Text #3

ACFB Publication #1 Text

ACFB Publication #1 Link

ACFB Publication #2 Text

ACFB Publication #2 Link

ACFB Publication #3 Text

ACFB Publication #3 Link

Professional Certification #1

Professional Certification #2

Professional Certification #3

Clinic Directory

The Counseling Collective

Location: 16 Taumutu Road

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