Professional Information Form "*" indicates required fields Contact InformationTitle Dr., Mrs., Miss, Mr., Other, etc.Name* First Last Primary Phone*Note: This phone number will be provided to clients for booking.What type of line is your primary phone?* Personal cell Home Work Work cell Can we text you at this number?* Yes No Alternate PhoneWhat type of line is your alternate phone? Personal cell Home Work Work cell Can we text you at this number? Yes No Email*Note: This email address will be provided to clients for booking. Alternate Email FaxWebsite/online profile Counselling ModalitiesIn Person* Yes No Telephone* Yes No Video* Yes No Name of PIPEDA-compliant video platform* Are you permitted and wanting to accept clients for video counselling from other Canadian provinces/jurisdictions? Yes No Please select the provinces/jurisdictions you’re able to see clients inCheck all that apply. Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Language(s)Working Language(s) for Counselling*Check all that apply. English French Other Other Working Language(s) Business AddressType of Address 1*Check all that apply. Billing Address Office 1 Office 2 Home Office Company Name* Address* Street Address Address Line 2 City Province Postal Code Office FeaturesCheck all that apply. Soundproof Business Licence Wheelchair Access Free Parking Private Entrance Animals (in home or office re: allergies, phobias) Office PhotosArete needs to ensure office spaces are suitable for our clients. Please upload photos of your office space, including all entries and waiting room(s). Drop files here or Select files Max. file size: 256 MB. Would you like to include another address?* Yes No Type of Address 2Check all that apply. Billing Address Office 1 Office 2 Home Office Company Name Address Street Address Address Line 2 City Province Postal Code Office FeaturesCheck all that apply. Soundproof Business Licence Wheelchair Access Free Parking Private Entrance Animals (in home or office re: allergies, phobias) Office PhotosArete needs to ensure office spaces are suitable for our clients. Please upload photos of your office space, including all entries and waiting room(s). Drop files here or Select files Max. file size: 256 MB. Would you like to include another address?* Yes No Type of Address 3Check all that apply. Billing Address Office 1 Office 2 Home Office Company Name Address Street Address Address Line 2 City Province Postal Code Office FeaturesCheck all that apply. Soundproof Business Licence Wheelchair Access Free Parking Private Entrance Animals (in home or office re: allergies, phobias) Office PhotosArete needs to ensure office spaces are suitable for our clients. Please upload photos of your office space, including all entries and waiting room(s). Drop files here or Select files Max. file size: 256 MB. Billing/Payment InformationName showing on your bank account* VOID Cheque*Payment is made via Direct Deposit (EFT). Please upload an image of a VOID cheque here for the account you wish to receive deposits to. Max. file size: 256 MB.Payment EmailAn email receipt will be sent to the email address you indicated above. If a different email address is preferred for these notifications, please note it here. Do you charge tax?* Yes No If yes, please Indicate:*GST#, HST# or QST# Professional InformationResume*Please attach a copy of your resume.Max. file size: 256 MB.Professional Designation*As stated on your registration. Highest Degree Obtained* Year Degree was Completed* Institution Degree was Obtained* List the regulatory body and/or association(s) of which you are a member in good standing*Please specify your registration number(s). Current Registration*Please attach a copy of your most current registration(s) that includes an expiry date(s). Drop files here or Select files Max. file size: 256 MB. What is your liability insurance coverage amount by incident?* Practice Insurance*Please attach a copy of your valid practice insurance that includes an expiry date.Max. file size: 256 MB. AvailabilityMorning (before 12 p.m.)Check all that apply. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Afternoon (12-5 p.m.)Check all that apply. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Evening (after 5 p.m.)Check all that apply. Monday Tuesday Wednesday Thursday Friday Saturday Sunday If you have multiple office locations, please specify which days of the week you are at each location. Critical Incident CounsellingDo you have any critical incident stress debriefing (CISD) experience? Yes No Do you have formal training in CISD? Yes No Are you able to do CISD sessions at a company location if needed? Yes No If yes, at which phone number could we contact you in case of an emergency? Disability Management/Return-to-Work SupportDo you have any experience supporting return-to-work assessments and treatment planning? Yes No Do you have formal training in supporting return-to-work assessments and treatment planning? Yes No Are you interested in receiving referrals from Arete for these specialized services? Yes No ClienteleClientele Served Children (0-11) Teenagers (12-17) Adults (18+) Elderly Couples Families Organizations Services OfferedAddiction IssuesSelect all that apply. Alcohol Addiction Assessments Drugs Family Substance Abuse Food Gambling Internet Relationships Sexual Specialized Family/Marital/Relationship IssuesSelect all that apply. Adoption Adoption - Specialized Aggressive Children Blended Family Caregiver support speciality Child Anxiety Child Play Therapy Child/Adolescent Christian-Based Counselling Couples/Relationship Difficulties Domestic Violence Domestic Violence Speciality Extended Family Mediation Multicultural Couples Counselling Parent-Child/Teen/Adult Relationships Parenting Issues Polyamorous Relationships School Problems Separation/Divorce Sexual Orientation Medical IssuesSelect all that apply. Acute Illness Cancer Specialist Support Chronic Disease/Illness Family Medical Issue Fertility issues/pregnancy loss Pain Management Terminal Illness Psychological IssuesSelect all that apply. Acute Stress/Adjustment Disorder ADD/ADHD Adults ADD/ADHD Children ADHD Specialty Anger Anxiety Autism Spectrum Disorder Autism Spectrum Disorder Specialty Bipolar Borderline Personality Disorder Specialty Boundaries Bullying Burnout CISD Cultural Issues Depression Dissociative Disorders Eating Disorder Eating Disorder Specialty Family Mental Health Issue FASD Gender Identity Gender Transition Grief/Bereavement Hypnosis Indigenous Specialization/Training Insomnia Learning/Functioning Issues 2SLGBTQ+ 2SLGBTQ+ Specialization Mood Disorder Natural Disaster New Immigrant Stressors Obsessive Compulsive Disorder Panic Attacks Paranoia Personality Disorder Phobias Postpartum Psychosis PTSD Relationship Difficulties Relaxation Schizophrenia Seasonal Affective Disorder Self-Harm Self-Esteem Sexual Abuse Sexual Dysfunction/Sex Therapy Spectrum Disorders Stress Tourette’s Speciality Trauma Veterans population Victim of Abuse Visualization Work-related IssuesSelect all that apply. Absenteeism/Tardiness Anxiety/Stress Burnout Career Assessments Career Issues Compassion Fatigue Co-Worker Issues Co-Worker/Peer Relations Disability absence (STD/LTD) Downsizing Harassment Injury Management/Supervisor Skills Organizational Change Potential Safety Risk Retirement Return-to-work Roles/Duties/Responsibilities Supervisor Relations Termination Vocational/Career Counselling Work-Life Balance Work Quality/Quantity Service Areas Not ListedIndicate any other service areas not listed that you provide services for (if any).Areas or Populations of Expertise/SpecializationIndicate your areas or populations of expertise/specialization (if any). Therapy Orientation and TrainingIf you're using a desktop or laptop and would like to select multiple entries for the questions in this section, hold the Ctrl key (PC) or Command key (Mac) and click on each item (using the mouse/trackpad).Therapy OrientationIndicate your major theoretical orientation(s). Select all that apply. ACT (Acceptance and Commitment Therapy) Adlerian Animal Assisted Therapy Art Therapy Attachment Therapy Avatar Training Biopsychosocial Bowen Family Systems Brief Therapy Cognitive Behavioural Therapy Clinical Hypnosis Cognitive Analytic Theory Conflict Resolution Couples Therapy Critical Incident Dance/Movement Therapy Dialectical Behaviour Therapy EMDR EMDR - Virtual Eclectic (Various) Ecotherapy Emotion-Focused Couple Therapy Emotionally Focused Therapy Equine-Assisted Therapy Existential Family Systems Feminist Gestalt Gottman Marital Therapy Hakomi Humanistic Impact Therapy Integrated Body Psychotherapy Intergenerational Trauma Internal Family Systems (Parts Work) Interpersonal Jungian Mindfulness Motivational Interviewing Narrative Therapy Neuro-Linguistic Programming Neurofeedback Neuropsychological Assessment Pastoral Perinatal Therapy Person-Centred Play Therapy Prolonged Exposure Psychedelic-Assisted Psychotherapy Psychodrama Psychodynamic/Analytic Psychoeducation/Insight Psychoeducational Assessments Rational-Emotive Therapy Reality Therapy Relational Rogerian Sandtray Satir Schema-Focused Therapy Self-Regulation Therapy Sensorimotor Psychotherapy Sex Addiction Therapy Sexoanalysis Short-Term Therapy Solution-Focused Therapy Somatic Spiritual Holistic Sport Psychology Systems/Interactional Trauma Trauma Sensorimotor Therapy Wilderness Trauma Training Yoga Therapy Therapy TrainingIndicate the area(s) in which you have had training, or are currently enrolled. Select all that apply. ACT (Acceptance and Commitment Therapy) Adlerian Animal Assisted Therapy Art Therapy Attachment Therapy Avatar Training Biopsychosocial Bowen Family Systems Brief Therapy Cognitive Behavioural Therapy Clinical Hypnosis Cognitive Analytic Theory Conflict Resolution Couples Therapy Critical Incident Dance/Movement Therapy Dialectical Behaviour Therapy EMDR EMDR - Virtual Eclectic (Various) Ecotherapy Emotion-Focused Couple Therapy Equine-Assisted Therapy Existential Family Systems Feminist Gestalt Gottman Marital Therapy Hakomi Humanistic Impact Therapy Integrated Body Psychotherapy Intergenerational Trauma Internal Family Systems (Parts Work) Interpersonal Jungian Mindfulness Motivational Interviewing Narrative Therapy Neuro-Linguistic Programming Neurofeedback Neuropsychological Assessment Pastoral Perinatal Therapy Person-Centred Play Therapy Prolonged Exposure Psychedelic-Assisted Psychotherapy Psychodrama Psychodynamic/Analytic Psychoeducation/Insight Psychoeducational Assessments Rational-Emotive Therapy Reality Therapy Relational Rogerian Sandtray Satir Schema-Focused Therapy Self-Regulation Therapy Sensorimotor Psychotherapy Sex Addiction Therapy Sex Analysis Sexoanalysis Short-Term Therapy Solution-Focused Therapy Somatic Spiritual Holistic Systems/Interactional Trauma Any other therapy orientation(s) not listed?Indicate any other major theoretical orientations you have experience with not listed. Any other therapy training not listed?Indicate any other therapy training you have that is not listed. Are you familiar with the current DSM? Yes No Are there any Community Mental Health Services or other support services in your area to which you can refer your clients when necessary? Yes No Training/Group/Employee FacilitationIf you would like to do any training/group facilitation for Arete, please list areas of expertise. About YouThis section is optional and collected only to assist Arete with the matching process. We aspire to have a Network with a wide variety of specializations and lived experiences that reflect the communities we support, and when clients request a counsellor with specific demographic characteristics and/or lived experiences we do our very best to accommodate them. Note that either withholding or providing information in this section will not impact your status as an affiliate. How would you describe yourself?ManWomanMan TransgenderWoman TransgenderNon-binaryTwo SpiritPrefer not to answerNot listedPlease note your preference Any other preferred language/clarification you’d like to note? What pronouns do you use? What race/ethnicity would you identify yourself as? Check all that apply. Asian Black European/White Hispanic Indigenous Pacific Islander Don't know Prefer not to answer Not listed Please note your preference Any other preferred language/clarification you’d like to note? What’s your religious affiliation? Check all that apply. Anglican Baptist Buddhist Greek Orthodox Hindu Jewish Lutheran Muslim Pentecostal Presbyterian Roman Catholic Sikh United Church Prefer not to say Not listed Please note your religious affiliation Any other preferred language/clarification you’d like to note? What's your birth date? DD slash MM slash YYYY Is there anything else about your own story and experiences you’d like to share that may help us match clients to you? Professional ConductHave you ever been charged with a criminal offence?* Yes No Have you ever been convicted of a criminal offence?* Yes No Are there outstanding complaints against you with a regulatory body?* Yes No Are there matters involving you currently under investigation by a regulatory body?* Yes No Are you under orders of discipline by a regulatory body?* Yes No Has a complaint ever been filed against you with a regulatory body?* Yes No Have you ever been dismissed from employment, on the grounds of professional misconduct in Canada or elsewhere?* Yes No Are you currently affected by any physical or mental condition that in any way impairs or limits your ability to practice counselling therapy, with safety, to the public?* Yes No Do you have any drug, alcohol or other addictions that in any way impair your ability to practice counselling therapy, with safety, to the public?* Yes No If you answered “yes” to any of the questions above, please provide details.* Arete ContactName of the person you've been communicating with at Arete* Carol G. Désirée E. Emily O. Gabrielle R. Gladys S. Eva S. Kathleen F. Paméla G. Sherry W.-H. Vanessa V. I'm not sure None ConsentConsent*By completing and submitting this form to Arete, I confirm that all statements are true and complete to the best of my knowledge and belief. I will advise Arete in a timely manner of any changes to the above information. I consent to the collection of this information and understand the purpose, which is to facilitate a match between a service user (Client) and affiliate (Clinician). This information is collected with the relevant applicable privacy laws, is housed in the secure Arete e-Tera™ database system and is available only to relevant Arete staff. The information enclosed may be discussed indirectly or directly with service users (Clients), but not publicly distributed. I confirm that all statements in this form are true and complete to the best of my knowledge and belief.*Date MM slash DD slash YYYY Δ