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*Listing Level:
*Basic
Deluxe
Premiere
*Note: Professional License will not be verified by arch-mc.org under Basic Listing
*Username:
(alphanumeric characters for username only)
*Email:
*Password:
*Confirm Password:
*Salutation:
No Preference
Dr.
Mr.
Mrs.
Ms.
Miss
*First Name:
*Last Name:
*Credentials:
*Company Name:
*Company Web Site URL:
*Street Address:
*City :
PHOENIX
ANTHEM
AVONDALE
AHWATUKEE
BUCKEYE
CHANDLER
EL MIRAGE
FOUNTAIN HILLS
GILA BEND
GILBERT
GLENDALE
GOODYEAR
LAVEEN
LITCHFIELD
MESA
PARADISE VALLEY
PEORIA
PHOENIX
SCOTTSDALE
SUN CITY
SUN CITY WEST
SURPRISE
TEMPE
TOLLESON
WICKENBURG
YOUNGTOWN
State :
Arizona
*Zip Code:
*Provider Category :
THERAPIST/COUNSELOR
PROVIDER FOR MEDICATIONS
PSYCHOLOGICAL EVALUATIONS
THERAPIST/COUNSELOR
DIETICIAN/NUTRITIONIST
COMMUNITY SUPPORT SERVICE
YOUTH GROUP
SELF HELP GROUP
RESIDENTIAL TREATMENT CENTER
IN-PATIENT TREATMENT CENTER
OUT-PATIENT TREATMENT CENTER
PSYCHIATRIC HOSPITAL
ALTERNATIVE TREATMENTS
*Provider Specialty #1:
Adolescents
Child or Adolescent Issues
Addictions/Substance Abuse
ADHD
Adolescents
Anxiety Disorders
Autism
Behavioral Problems
Bipolar Disorders
Body Dysmorphic Disorder
Eating Disorders
Family Support
Grief and Loss
Impulse Control Disorders
Mood Disorders
OCD
Parenting Support
Personality Disorders
Psychosis/Hallucinations
PTSD/Trauma
Self-Harm/Cutting
Sleep Disorders
Specific Fears
Thinking Disorders
(Required For All Listing Levels)
Provider Specialty #2:
None
None
Child or Adolescent Issues
Addictions/Substance Abuse
ADHD
Adolescents
Anxiety Disorders
Autism
Behavioral Problems
Bipolar Disorders
Body Dysmorphic Disorder
Eating Disorders
Family Support
Grief and Loss
Impulse Control Disorders
Mood Disorders
OCD
Parenting Support
Personality Disorders
Psychosis/Hallucinations
PTSD/Trauma
Self-Harm/Cutting
Sleep Disorders
Specific Fears
Thinking Disorders
(Available in Deluxe & Premiere Only)
Provider Specialty #3:
None
None
Child or Adolescent Issues
Addictions/Substance Abuse
ADHD
Adolescents
Anxiety Disorders
Autism
Behavioral Problems
Bipolar Disorders
Body Dysmorphic Disorder
Eating Disorders
Family Support
Grief and Loss
Impulse Control Disorders
Mood Disorders
OCD
Parenting Support
Personality Disorders
Psychosis/Hallucinations
PTSD/Trauma
Self-Harm/Cutting
Sleep Disorders
Specific Fears
Thinking Disorders
(Available in Deluxe & Premiere Only)
Provider Specialty #4:
None
None
Child or Adolescent Issues
Addictions/Substance Abuse
ADHD
Adolescents
Anxiety Disorders
Autism
Behavioral Problems
Bipolar Disorders
Body Dysmorphic Disorder
Eating Disorders
Family Support
Grief and Loss
Impulse Control Disorders
Mood Disorders
OCD
Parenting Support
Personality Disorders
Psychosis/Hallucinations
PTSD/Trauma
Self-Harm/Cutting
Sleep Disorders
Specific Fears
Thinking Disorders
(Available in Premiere Only)
Provider Specialty #5:
None
None
Child or Adolescent Issues
Addictions/Substance Abuse
ADHD
Adolescents
Anxiety Disorders
Autism
Behavioral Problems
Bipolar Disorders
Body Dysmorphic Disorder
Eating Disorders
Family Support
Grief and Loss
Impulse Control Disorders
Mood Disorders
OCD
Parenting Support
Personality Disorders
Psychosis/Hallucinations
PTSD/Trauma
Self-Harm/Cutting
Sleep Disorders
Specific Fears
Thinking Disorders
(Available in Premiere Only)
Provider Specialty #6:
None
None
Child or Adolescent Issues
Addictions/Substance Abuse
ADHD
Adolescents
Anxiety Disorders
Autism
Behavioral Problems
Bipolar Disorders
Body Dysmorphic Disorder
Eating Disorders
Family Support
Grief and Loss
Impulse Control Disorders
Mood Disorders
OCD
Parenting Support
Personality Disorders
Psychosis/Hallucinations
PTSD/Trauma
Self-Harm/Cutting
Sleep Disorders
Specific Fears
Thinking Disorders
(Available in Premiere Only)
Provider Specialty #7:
None
None
Child or Adolescent Issues
Addictions/Substance Abuse
ADHD
Adolescents
Anxiety Disorders
Autism
Behavioral Problems
Bipolar Disorders
Body Dysmorphic Disorder
Eating Disorders
Family Support
Grief and Loss
Impulse Control Disorders
Mood Disorders
OCD
Parenting Support
Personality Disorders
Psychosis/Hallucinations
PTSD/Trauma
Self-Harm/Cutting
Sleep Disorders
Specific Fears
Thinking Disorders
(Available in Premiere Only)
*Accept Insurance :
No
Yes
No
Insurances Accepted:
*Accept Credit Cards :
No
Yes
No
*Spanish Speaking Provider :
No
Yes
No
*Faith Based :
No
Yes
No
*Therapist's Gender :
Female
Male
Female
No Preference
Years in Practice:
Graduate School:
Year Graduated:
*Phone:
Digits Only
Fax:
Digits Only
*Fees:
Professional License Number:
*Professional License Type:
No Arizona License Required
CARF
JCAHO
MD
NMD
DO
PA
NP
CNS
Ph.D
Psy.D
LCSW
LMSW
LPC
LMFT
LISAC
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