| Resource Type: | |||||||
| Physician | Therapist | Interventionist | Continuing Care Facility | ||||
| First Name: | |||||
| Middle Initial: | |||||
| Last Name and Credentials: | |||||
| Years in Practice: | |||||
| Organization: | |||||
| Qualifications: | |||||
| Description of Services: | |||||
| Address 1: | |||||
| Address 2: | |||||
| City: | |||||
| State/Province: | |||||
| Zip: | |||||
| Country: | |||||
| Phone 1: | |||||
| Phone 2: | |||||
| Fax: | |||||
| Email: | |||||
| Web Site: | |||||
| Specialty Areas: | |||||
| Axis II Disorders | CD/Alcohol | Compulsive Gambling | |||
| Eating Disorders | Internet Addiction | Mood Disorders | |||
| Sexual Addiction | Trauma | Other | |||
| Modalities: | |||||
| Children | Adolescent | Family | |||
| Couples | Individual | Group | |||
| EMDR | Experiential | Interventions | |||
| Psychodrama | Other | ||||
| Type of Service: | |||||
| Acute Care | Extended Care | Halfway House | |||
| Inpatient/Hospital | IOP | Outpatient | |||
| Partial Hosp/Day Program | Residential | Other | |||
| Fee Range: | |
| Length of Stay: |
| Accept: | |||||
| Medicare | Insurance | Private Pay | |||
| Please describe your philosophy in 50 words or less: |
| By submitting this form, I hereby authorize Seabrook House to include the above information on their database and to publish such information on Seabrook House's website. | |
| I agree to receive information or contact by Seabrook House. | |
| *Note: Please be advised that Seabrook House will evaluate all submissions and will retain the right to add or subtract listings from the Seabrook House website at their discretion. Submission of this form does not guarantee inclusion on Seabrook House’s website. Seabrook House cannot be held liable for the accuracy of information submitted or displayed. Applicant agrees to release and hold harmless Seabrook House and all of its subsidiaries, owners, officers, directors, employees, and agents from any and all liability relating to the use of any information contained herein. | |
