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(914) 723-3030

 

 

WCPA's Directory Questionnaire

Please TYPE or PRINT all information as you would like your listing to read.  IF YOU HAVE A CHANGE OF LISTING OR WERE NOT INCLUDED IN THE LAST DIRECTORY, THIS IS THE ONLY WAY TO BE LISTED.  ONLY MEMBERS WHOSE DUES ARE CURRENTLY PAID WILL BE LISTED.   

DEADLINE:  JULY 1, 2016

Name:        Highest Degree:

Check address(es) you wish listed in the Directory, including apartment or suite number.

  Home Address:

Home Telephone:

  Office Address:

Office Telephone: Fax #:

E-mail:

Office Address:  

Office Telephone:

Psychologist License #:      State:

School Psychologist Certification #    State:

Diplomate, ABPP: Clinical     Counseling   Group     School     Hypnosis   
Neuropsychology

SCHOOL PSYCHOLOGISTS: 
Please list your School:

District/Address:

Telephone #:

Major Field (Please note: This section is intended for psychologists & students in academic & teaching settings. Limit 3 fields)

Clinical Neuropsych                          Experimental Psych                 Psychology of Women                
Clinical Psychology                             Forensic Psych                          Psychopharmacology

Community Psych                               Industrial/Organizational          Rehabilitation Psych                             
Counseling Psych                               Medical Psych                            School Psych

Developmental Psych                          Personality Psych                          Social Psych

Educational Psych                              Physiological Psych                              

Environmental Psych                        Professional Psych  

Other (specify):          

Professional Setting  (check as many as apply):

Independent Practice                     Correctional Facility                University/College

Industry                                        Hospital                               Social Agency

Developmental Ctr                         Clinic                                   Medical

Psychiatric Center                          School                           

Other (specify):

If in independent practice, please check all that apply below.  You must give license # above.

Psychotherapy         Psychological Testing           Educational Testing            Vocational Testing

Children                  Children                             Children                         Children
Adolescents            Adolescents                        Adolescents                     Adolescents
Adults                      Adults                                 Adults                            Adults
Family
Couple
Group

State specialty practice (e.g., behavior therapy, biofeedback, psychoanalysis, etc.) only if you are in independent practice.
(Maximum three specialties):

 

Do you accept Medicaid? Yes No

Languages fluent in:

Are you a member of APA: Yes No      NYSPA Yes No