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Referral Directory Form

The aim of the referral directory is to offer a resource outlining available mental health resources, across professional disciplines, and arranged in a way that facilitates ensuring that proper referrals are made. The Directory will provide an alphabetical listing of all providers, but will also subdivide the entries by professional discipline, location, specialty areas, etc.

We realize that you are being asked to provide a lot of information, but our aim is to be as complete and inclusive as possible. This Directory will be widely distributed to those who attend our seminars (mental health professionals, lawyers, judges, etc.). The Directory should facilitate practice-building, professional networking, and referrals. This is a small effort directed at bringing together, in a collegial rather than divisive way, mental health resources in our state. Thank you for your participation.

Note: Please check all that apply. Please do not provide information that you do not want published in the Referral Directory. Please try to ensure that all information provided is accurate and clear. Add additional explanations on separate pages if necessary. If you still have questions, please call Lisa Driscoll at 318-443-0845 or email PTR at ptr@suddenlinkmail.com.

Username
Password
Email
Display email	yes No Do you want your email to be displayed in directory searches?
First name
Middle Name/Initial
Last name
Nick name
Age
Gender	Male Female
Prefix	Dr. Fr. Mr. Mrs. Ms. Rev. Sr.
Other
Suffix	ACNP-BC ANP-BC B.A. B.S. D.Div. D.S.W. DNP DNSC Ed.D. FNP-BC FPMHNP GNP-BC J.D. L.A.C. L.C.S.W. L.M.F.T. L.P.C. L.P.N. L.R.C. M.A. M.D. M.Div. M.P. M.S. M.S.W. P.A. Ph.D. PNP-BC Psy.D. R.N. Th.D. WHNP-BC
Other
Office name of business
Office mailing address
Office physical address line 1
Office physical address line 2
Office city
Office state
Office postal code
Office primary phone with ext
Office secondary phone with ext
Office Fax #
Office mobile phone
Office email address
Office website url
Office other contact information
Region of state of primary business address	Baton Rouge Area Central (Alexandria Area) Central East (Jonesville/Ferriday Area) Central West (Leesville/DeRidder Area) New Orleans Area North Central (Ruston Area) Northeast (Monroe Area) Northwest (Shreveport Area) South Central (Lafayette Area) South East (North of Lake Ponchartrain) (Covington/Slidell Area) South East (South of Lake Ponchartrain) (Houma/Morgan City Area) Southwest (Lake Charles Area) Other
Other
Region of state served	Baton Rouge Area Central (Alexandria Area) Central East (Jonesville/Ferriday Area) Central West (Leesville/DeRidder Area) New Orleans Area North Central (Ruston Area) Northeast (Monroe Area) Northwest (Shreveport Area) South Central (Lafayette Area) South East (North of Lake Ponchartrain) (Covington/Slidell Area) South East (South of Lake Ponchartrain) (Houma/Morgan City Area) Southwest (Lake Charles Area) Other
Other
Office2 name of business
Office2 mailing address
Office2 physical address line 1
Office2 physical address line 2
Office2 city
Office2 state
Office2 postal code
Office2 primary phone with ext
Office2 secondary phone with ext
Office2 Fax #
Office2 mobile phone
Office2 email address
Office2 website url
Office2 other contact information
Home mailing address
Home physical address line 1
Home physical address line 2
Home city
Home state
Home postal code
Home primary phone with ext
Home secondary phone with ext
Home Fax #
Home mobile phone
Home email address
Home other contact information
Profession:
Psychologist (Licensed by the Louisiana State Board of Examiners of Psychologists)
Psychology License #
Psychology licenses	Clinical Clinical Neuropsychologist Counseling Developmental Educational Emeritus Experimental Industrial/Organizational Medical Psychologist School Social A.B.P.P. (American Board of Professional Psychology) Other
Other
Abpp speciality areas	Clinical Child and Adolescent Psychology Clinical Health Psychology Clinical Neuropsychology Clinical Psychology Cognitive & Behavioral Psychology Counseling Psychology Forensic Psychology Group Psychology Organizational & Business Consulting Psychology Psychoanalysis in Psychology Rehabilitation Psychology School Psychology
Social Worker (Licensed by the Louisiana State Board of Social Work Examiners)
Social License #
Social licenses	Graduate Social Worker LCSW LCSW-BACS Provisional GSW Registered Social Worker Other
Other
Licensed Professional Counselor (Licensed by the Licensed Professional Counselors Board of Examiners)
Counselor License #
Counselor licenses	Counselor Intern LMFT LMFT Supervisor LPC LPC Supervisor MFT Intern Privileged LPC Other
Other
Substance Abuse Counselor (Licensed by the Louisiana Association of Substance Abuse Counselors & Trainers, Inc.)
Substance Counselor #
Substance counselor licenses	Addiction Treatment Assistant (ATA) Certified Addiction Counselor (CAC) Certified Clinical Supervisor (CCS) Certified Compulsive Gambling Counselor (CCGC) Certified Criminal Justice Professional (CCJP) Certified Prevention Professional (CPP) Counselor in Training (CIT) Licensed Addiction Counselor (LAC) Licensed Prevention Professional (LPP) Prevention Specialist in Training (PSIT) Registered Addiction Counselor (RAC) Registered Prevention Professional (RPP) Registered Preventionist (RP) Other
Other
Vocational Rehabilitation Counselors (Licensed by the Louisiana Licensed Professional Vocational Rehabilitation Counselors Board of Examiners)
Vocation License #
Vocation licenses	Licensed Professional Vocational Rehabilitation Counselor Licensed Professional Vocational Rehabilitation Counselor -- Supervisor Provisional Licensed Professional Vocational Rehabilitation Counselor Other
Other
Nurse Practitioners (Louisiana Association of Nurse Practitioners)
Membership type	Regular Student Associate Retired
Aprn preparation	Certificate Bachelor's Master's Doctorate
Type of program	Acute Care NP Adult NP Family NP Gerontological NP Midwife Neonatal NP Pediatric NP Psych/Mental Health Women’s Health/OB Other
Other
Highest level achieved	Diploma ADN BSN MSN DNS DNP Associate Other Bachelors Other
Services Provided: Please check off the areas of your expertise:
Age groups	Infants/Toddlers Pre-School School-Age Early Adolescence Mid-Adolescence Late-Adolescence Young Adults Adults Mid-Life Late-Life
General therapy modalities	12-Step Christian Counseling Faith-Based Counseling Family Therapy Group Therapy Individual Therapy Marital Therapy Marriage and Family Therapy Pastoral Counseling
Other
Specific therapies offered	Accelerated Experiential Dynamic Psychotherapy Acceptance & Commitment Therapy Adlerian Therapy Adolescent Therapy Group Anger Management Art Therapy Authentic Movement Autogenic Training Behavior Therapy Bioenergetic Analysis Biofeedback Body Psychotherapy Body Talk system Body-Mind Psychotherapy Breathwork Clean Language Therapy Client Centered Therapy Client-Directed Outcome-Informed Therapy Cognitive-Behavioral Therapy Coherence Therapy Collaborative Divorce Collaborative Therapy Conflict Resolution Therapy Constructivism Contemplative Approaches Contemplative Psychotherapy Continuum Therapy Control Mastery Theory Core Energetics Core Process Psychotherapy Crisis Intervention Critical Incidence Stress Debriefing D.B.T. (Dialectical Behavior Therapy) Dance Therapy Depth Hypnosis Depth Therapy Depth-Oriented Brief Therapy Developmental Needs Meeting Strategy Drama Therapy Dream Analysis Dreamwork Dyadic Developmental Psychotherapy E.M.D.R. (Eye Movement Desensitization Reprocessing) Ecotherapy Emotional Freedom Technique Emotional Transformation Therapy Emotionally Focused Couples Therapy Energy Psychology Equine & Animal Assisted Therapies Existential Therapy Experiential Therapy for Couples Family Attachment Narrative Therapy Family Constellations Family Therapy Feldehkrais Method Feminist Therapy Filial Therapy Fitness Psychology Focalizing Focusing Gestalt Therapy Gottman Method Grief Counseling Guided Therapeutic Imagery Hakomi Healing Touch Holistic Psychotherapy Holographic Memory Resolution Holotropic Breathwork Human Givens Humanist-Existential Humanistic Psychology Hypnosis Hypnotherapy Imago Relationship Therapy Integral Psychotherapy Integrative Body Psychotherapy Intensive short-Term Dynamic Psychotherapy Internal Family Systems Interpersonal Neurobiology Interpersonal Psychotherapy InterPlay Journey Therapy Jungian Psychotherapy Lifespan Integration Light Therapy Logotherapy M.S.T. (Multisystemic Therapy) Men’s Therapy Group Metaphor Therapy Middendorf Breath Experience Mindfulness Based Approaches Mindfulness Based Cognitive Therapy Motivational Enhancement Therapy Movement Therapy Music Therapy Narrative Therapy Nature Therapy Neuro-Linguistic Programming Neurofeedback Non-Violent Communication Object Relations Parent Training Parent Work Parent-Child Interaction Therapy Parenting Coordination Peaceful Divorce Person Centered Play Therapy Poetry Therapy Positive Psychology Positive Psychotherapy Possibility Therapy Pragmatic Therapy Process Oriented Psychology Psycho-Physical Therapy Psycho-Shamanic Psychoanalysis Psychoanalysis – Modern Psychodrama Psychodynamic Therapy Psychodynamic Therapy Psychomotor Psychosynthesis Radiant Heart Therapy Rational-Emotive Therapy Reality Therapy Redecision Therapy Regression Therapy Relational Psychotherapy Relational Recovery Relationship Enhancement Therapy Relchian Breathwork Rogerian Therapy Rubenfield Syndergy Method Sand Tray Therapy Satir Transformational Systemic Therapy Schema Therapy Self Psychology Self Relations Self-Acceptance Training Sensorimotor Psychotherapy Sex-Offender Sexual Abuse Survivors Shamanic Journeying Solution-Focused Therapy Somatic Experiencing Somatic Psychotherapy Soul-Centered Psychiatry Sports Psychology Symbolic Modeling Therapy Systems Theory Systems Therapy Theraplay Thought Field Therapy Timeline Therapy Transactional Analysis Transpersonal Psychotherapy Transpersonal Therapy Trauma Relief Unlimited Trauma-Focused Cognitive Behavioral Therapy Trauma-Focused Therapy Voice Dialogue Wilderness Therapy Women's Therapy Group Yoga Therapy
Other
Diagnostic groups	Addictive Disorders Adjustment Disorders Affective (Mood) Disorders Anxiety Disorders Cognitive Disorders (e.g., Delirium, Dementia, Amnestic Disorders) Communication Disorders Disruptive Behavior Disorders Dissociative Disorders Eating Disorders Elimination Disorders Factitious Disorders Gender Identity Disorders Impulse-Control Disorders Learning Disorders Personality Disorders Pervasive Developmental Disorders Psychotic Disorders Sexual Disorders Sexual Dysfunctions Sleep Disorders Somatoform Disorders Substance Related Disorders
Other information important for colleagues to know

Referral Directory Form

Profession:

Psychologist (Licensed by the Louisiana State Board of Examiners of Psychologists)

Social Worker (Licensed by the Louisiana State Board of Social Work Examiners)

Licensed Professional Counselor (Licensed by the Licensed Professional Counselors Board of Examiners)

Substance Abuse Counselor (Licensed by the Louisiana Association of Substance Abuse Counselors & Trainers, Inc.)

Vocational Rehabilitation Counselors (Licensed by the Louisiana Licensed Professional Vocational Rehabilitation Counselors Board of Examiners)

Nurse Practitioners (Louisiana Association of Nurse Practitioners)

Services Provided: Please check off the areas of your expertise: