Professional Resource Network Profile

Please fill out the Professional Profile form if you would like to be a resource for clients returning to your community or if you would like to learn more about Promises Treatment Centers. You can also use this form to update your information with Promises.

Last Name:

First Name:

Credentials:

Email:

Practice Name:

Position:

Primary Practice Address:

City:

State:

Zip:

Secondary Practice Address:

City:

State:

Zip:

Office Phone:

Cell Phone:

Website:

Practice:

Outpatient (Individual, Couples, Family)
Physician
Psychiatrist
Pain Management Clinic
Intensive Outpatient Program (IOP)
Partial Day Program (PHP)
Residential Treatment Facility
Inpatient Hospital Program
Transitional Living Facility
Interventionist
Life Coach or Sober Companion
Educational Consultant

Population Served:

18 and AboveGLBT
AdolescentsMen Only
Children under 16Women Only
GeriatricCouples
Families

Insurance:

Takes InsuranceCigna
Private PayMedicare
UBHMedicaid
AetnaOther
BC/BS

Specialization (please check all that apply):

ADD/ADHDDual DiagnosisMeditationRapid Detox
AlanonEating DisordersMethadone MaintRecreational Therapy
Alumni ProgramEMDRNeuro FeedbackRelapse Prevention
Anger ManagementEquine TherapyNicotine CessationSelf Abuse/Self Harm
AnxietyFemale IssuesNutritional GuidanceSex Addiction
Art TherapyFitness ProgramOCDSexual Abuse/Rape
Bio FeedbackGambling AddictionPain MgmtSleeping Disorder
Bi PolarGestalt TechniquesParenting SkillsSomatic Therapy
Co-DependencyGrief/LossPersonality DisorderSpiritual Counseling
Cognitive Behavioral TherapyHIV CounselingProcess GroupStag Group
DepressionHolistic ApproachPsychiatric ServicesSteroid Abuse
DetoxHypnotherapyPsychodramaSubstance Abuse Specialist
DBTLearning DisabilitiesPsychotherapyTrauma
Drug & Alcohol TestingLife Skills CoachingPTSDViolence/Physical Abuse
Drug EducationMed Management

Groups Description:

Time:

Days:

Cost:

Workshops Description:

Time:

Days:

Cost:

Your Sober Birthday (Optional):

Your Birthday (Optional):

Other Information: