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| Contact Information | ||||||
| * FirstName: Enter your FIRST NAME | ||||||
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Please write your answer here: |
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| * LastName: Enter your LAST NAME | ||||||
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Please write your answer here: |
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| * Degree: Enter your professional DEGREE | ||||||
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Please write your answer here: |
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| Primary Practice Location | ||||||
| PracticeName1: Enter your Primary Practice NAME (If applicable) | ||||||
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Please write your answer here: |
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| * PracticeStreet1: Enter your Primary Practice STREET ADDRESS | ||||||
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Please write your answer here: |
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| * PracticeCity1: Enter the Primary Practice CITY | ||||||
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Please write your answer here: |
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| * PracticeState1: Enter your Primary Practice STATE | ||||||
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Please choose *only one* of the following: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming |
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| * PracticeZip1: Enter your Primary Practice ZIP CODE | ||||||
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Please write your answer here: |
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| PracticeFax1: Enter your Primary Practice FAX NUMBER | ||||||
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Please write your answer here: |
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| * PracticePhone1: Enter your Primary Practice PHONE NUMBER | ||||||
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Please write your answer here: |
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| PracticeEMail1: Enter your Primary Practice E-MAIL ADDRESS | ||||||
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Please write your answer here: |
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| PracticeWebsite1: Enter your Primary Practice WEB ADDRESS | ||||||
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Please write your answer here: |
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| Second Practice Location (If Applicable) | ||||||
| PracticeName2: Enter your Second Practice NAME (If applicable) | ||||||
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Please write your answer here: |
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| PracticeStreet2: Enter your Second Practice STREET ADDRESS | ||||||
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Please write your answer here: |
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| PracticeCity2: Enter your Second Practice CITY | ||||||
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Please write your answer here: |
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| PracticeState2: Enter your Second Practice STATE | ||||||
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Please choose *only one* of the following: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming |
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| PracticeZip2: Enter your Second Practice ZIP CODE | ||||||
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Please write your answer here: |
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| PracticePhone2: Enter your Second Practice PHONE NUMBER | ||||||
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Please write your answer here: |
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| PracticeFax2: Enter your Second Practice FAX NUMBER | ||||||
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Please write your answer here: |
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| PracticeEMail2: Enter your Second Practice E-MAIL ADDRESS | ||||||
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Please write your answer here: |
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| PracticeWebsite2: Enter your Second Practice WEB ADDRESS | ||||||
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Please write your answer here: |
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| Professional Information | ||||||
| Profession: | ||||||
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Please choose *all* that apply: Psychologist Psychiatrist Social Worker Marital / Family Therapist Psychiatric Nurse Other: |
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| DegreeFrom: Enter the NAME of the College/University your Degree is from | ||||||
Please write your answer(s) here:
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| PostDegree: Enter LOCATION and DATES of your Internship and/or Post Degree Training | ||||||
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Please write your answer here: |
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| License: Enter your License STATE, YEAR and NUMBER | ||||||
Please write your answer(s) here:
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| Insured: Do you carry Malpractice Insurance ? | ||||||
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Please choose *only one* of the following: Yes No |
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| [Only answer this question if you answered 'Yes' to question 'Insured '] | ||||||
| Liability: Enter your Malpractice Insurance LIABILITY | ||||||
Please write your answer(s) here:
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| Decisions: Do you have any malpractice decisions against you or pending? | ||||||
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Please choose *only one* of the following: Yes No |
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| Practice Information | ||||||
| WorkWith: Select the GROUPS you work with | ||||||
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Please choose *all* that apply: Individuals Couples Groups Families |
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| Specialty: Enter your AREAS OF SPECIALTY | ||||||
Please write your answer(s) here:
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| Infert: Select the PERCENTAGE of your practice dealing with infertility | ||||||
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Please choose *only one* of the following: Less than 25% Between 25 and 50 percent Between 50 and 75 percent Over 75 percent |
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| Experience: Enter tour training and experience in infertility, family building and reproductive health issues (please be sure to specify training/experience in your specialty areas): | ||||||
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Please write your answer here: |
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| Groups: Enter your experience in facilitating infertility groups/other groups: | ||||||
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Please write your answer here: |
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Acknowledgment: I understand that my participation in the AFA Therapist Network is voluntary and that my inclusion or removal from the Network is at the AFA’s sole discretion. |
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