ARG:Intervention Services Directory Questionnaire

Intervention Services Directory Information Questionnaire

Directions: Print out the following questionnaire. Fill it out completely and accurately, to obtain an Intervention Services Directory listing. Join now and receive the listing FREE for six (6) months. At the end of six (6) months you can continue to be listed in the directory for the reasonable yearly fee of $100.

If you have questions, please email, Polly Waldman at pbw@addictionresourceguide.com. Fax the completed form to 914.631.8077 or mail it to Addiction Resource Guide, P.O. Box 8612, Tarrytown, NY 10591, Attn: Polly Waldman.

Name ___________________________________________________

Please check your TYPE OF PRACTICE.

[ ] Solo

[ ] Group

[ ] Firm

[ ] Associated with a Treatment Facility

If yes, name of facility: ____________________________

What types of Interventons do you facilitate? (check all that apply)

[ ] Crisis

[ ] Family

[ ] Executive/Workplace

Where are your services available? (check all that apply)

[ ] Locally _________________________________________ (city and/or state)

[ ] Regionally (US)

[ ] Internationally

What addictions, self-destructive behaviors do you work with? (check all that apply)

[ ] Alcohol

[ ] Eating Disorders

[ ] Gambling

[ ] Other Drugs

[ ] Sexual Addictions

[ ] Other, please specify: ______________________________________

1. Describe your intervention services in less than 100 words. (What makes you different and special!)

2. What advice would you give to prospective clients?

3. Give an overview of your practice in one or two sentences.

4. What special training do you or your staff have?

Pricing Information

Cost for Intervention: _____________________________________________

Travel expenses included: [ ] Yes [ ] No

If NO, how is cost calculated? _____________________________________

Arrangements possible for insurance coverage?[ ] Yes [ ] No

If YES, how is coverage handled? _____________________________________

Staff:

How many people are on the staff? __________________________________

List types of licenses held by the staff:___________________________

Accreditations or Certifications:___________________________________

Contact Information

General Telephone Number: _____________________

24 Hour HOTLINE: ________________________

Address __________________________________________

__________________________________________

Contact Person for future update and WEB related Business

Name: ___________________________________

Title: __________________________________

E-mail address: _________________________

Fax Number: _____________________________

Do you have a website, and if so what is the URL: ______________________

Fax completed questionnaire to:

Addiction Resource Guide, Fax #: 914.631.8077

or mail the completed questionnaire to:

Addiction Resource Guide, P.O. Box 8612, Tarrytown, New York 10591