DePaul UCS Referred Provider Survey

Clinician Headshot Picture

DePaul UCS Affiliation *

Provider Group *

First Name *

Last Name *

Email *

Phone *

Street Address *

City *

Zip Code *

Psychology Today Weblink (enter N/A if you have no profile) *

Practice Website (enter N/A if you have no website) *

Referrals Contact *

Referrals Contact Name

Referrals Contact Email

Referrals Contact Phone

Clinician Type *

Other Clinician Type

Med Management and Psychotherapy *

Med Management Alone *

Require Psychotherapy with Med Management *

Assess and Treat Eating DO *

Assess and Treat ADHD *

Assess and Treat Bipolar DO *

Assess and Treat Psychotic DO *

Board Certified in General Psychiatry *

Board Certified in Child and Adolscent Psychiatry *

Board Certified in Addiction Psychiatry *

Clinician Degree *Ph.D.
Psy.D.
Ed.D.
M.D.
D.O.
M.S.W.
M.A.
M.S.
M.Ed.
M.B.A.
J.D.
Other

Other Clinician Degrees

Illinois License Status *

Practice Type *

Public Transit Access *

Early Morning (before 9:00 am) Appointments *

Daytime (9:00 am - 5:00 pm) Appointments *

Evening (after 5:00 pm) Appointments *

Weekend Appointments *

Telehealth/Online Appointments *

Health Insurance *

Insurance Company *Aetna
BCBS HMO
BCBS PPO
BCBS Blue Choice
Cigna
Humana
PHCS
United Health Care/UBH
Other

Other Insurance Accepted

Regular Fee *

Sliding Scale (Do you have any capacity for sliding scale/flexible frees for college students? *

Sliding Scale Range (please pick low and high) *$5
$10
$20
$30
$40
$50
$60
$70
$80
$90
$100
Other

Other Sliding Scale Range

Theoretical Orientation/Approach *ACT (Acceptance and Commitment Therapy)
CBT (Cognitive Bahavioral Therapy)
Cross-Cultural Approach
Eclectic / Integrative
Existential
Feminist
Humanistic / Person Centered
Psychodynamic
Systems

Specialized Training or Other CertificationsABA (Applied Behavioral Analysis)
ACT (Acceptance and Commitment Therapy)
Addictions
Anger Management
Body-based Trauma Therapy
Art Therapy
Coaching
Couples Counseling
Couples Counseling-Emotion Focused Method
Couples Counseling-Gottman Method
Cross-Cultural Approach
DBT (Dialectical Behavior Therapy)
Eating Disorders
EMDR (Eye Movement Desensitization and Reprocessing)
Family Therapy
Hypnotherapy
Mindfulness
Mindfulness-based Cognitive Therapy
Parent Education
Prolonged Exposure Therapy
Psychoanalysis

Other Specialized Training or Other Certifications

Diagnose/Condition-Specific Specialized TrainingAutism Spectrum
ADHD (Attention Deficit Hyperactivity Disorder)
LD (Learning Disabilities)
Bereavement
Bipolar Disorder
Body Disphoria
Eating Disorders
Health Concerns (Chronic Illness/pain management)
Internet/Gaming Addiction
OCD (Obsessive Compulsive Disorder)
Pornography Addiction/Sex Addiction
Psychosis
PTSD (Post Traumatic Stress Disorder)
Sexual Assault
Sexual Concerns

Other Diagnose/Condition-Specific Specialized Training

Clinician DemographicsAsian/Pacific Islander
Black/African-American
Hispanic/Latinx
Middle Eastern
Multiracial
Native American/American Indian
South Asian
White/Caucasian
Male
Female
Trans
Gender non-conforming/Non-binary
Gay/Lesbian/Bisexual
Muslim
Buddhist
Hindu
Christian
Jewish
Sikh

Other Clinician Demographics

Special PopulationsGay,Lesbian,Bisexual,Queer
Transgender or gender non-conforming
People with disabilities
Immigrants or Refugees
People of Color

Other Special Populations

Clients that are good fit for your practice

Clients that are not good fit for your practice

Languages Used in Therapy *Arabic
Chinese (Cantonese)
Chinese (Mandarin)
English
French
Hindi
Korean
Polish
Spanish
Urdu
Other

Other Languages Used in Therapy

Support Services

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