CONTACT Name *
CREDENTIALS Clinician Type *
Please share what type of clinician you are. If OTHER, please specify in the comments area below.
Licensed Therapist Registered Associate MFT Psychologist Psychiatrist Life Coach Other Years working with YOUTH *
How many years do you have specifically working with youth, ages 5-25 in your practice (including your internship/residency/post-doctoral)?
0-2 3-5 6+ ABOUT YOUR PRACTICE Waiting List *
Please let us know if you currently have a waiting list. This helps us to know if we are making a referral.
YES NO ON OCCASSION LOCATION *
What areas of Santa Barbara County do you serve?
Do you provide telehealth counseling services? Please choose "on occassion" if this is not common in your practice.
YES NO ON OCCASSION Ages served *
Please share what ages you serve in your practice.
Do you speak, English, Spanish or are you bilingual?
English Spanish Bilingual Specialities - Modalities *
Please list any specialties related to youth and families.
Do you do EMDR, play therapy, bereavement/grief, sexual assault, eating disorders, substance use, etc.
FEES Sliding Scale *
Do you provide a sliding scale for fees in your practice?
Yes No Insurance *
Do you take insurance? And if no, do you provide a superbill so that individuals can submit on their own?
Yes No No-Provide Superbill Rates & Fees *
Please specify your overall rates for providing services. If you offer a sliding scale, please specify those rates as well.