Member Directory Form

Louisiana Association of Clinical Social Workers

P.O. Box 14153

Baton Rouge, LA. 70808

225-932-0053

Member Directory Form

Dear Member,

We welcome you to enter your information to our member database. This will aid consumers being able to seek assistance with specific issues. Thank you for your assistance in this effort to better serve our community. List only information you want published on the website or membership directory.

New Entry Updated Entry

Last Name First Name MI/Nic Name

Group/Org Name Work Phone Fax

Home Phone Email address

Mailing Address City State Zip

Website

Physical Address City State Zip

Clinical Practice Area Designation

Populations Served: (check all that apply)

Children Adolescents Adults Geriatrics

Cultural Issues: (check all that apply)

African American Asians Hispanics

Modalities: (check all that apply)

Individual Therapy Couple Therapy Group Therapy Family Therapy

Specialty Groups:

Therapeutic Models/Approaches:

Please indicate your primary area(s) of practice:

Adoption	End of life issues	Mood disorders
Anxiety disorders	Family violence-victims	Parenting issues
ADD	Family violence-offenders	Personality disorders
Chemical dependency	Forensic	Phobias
Child/sex abuse – victim	Gay/lesbian	Physically challenged
Child/sex abuse-offender	General practice	Sexual addiction
Childhood abuse/trauma	Grief/bereavement	Sexual dysfunction
Compulsive Gambling	HIV	Sexual trauma
Custody Evaluations	Home health services	Thought disorders
Developmentally disabled	Marital/divorce	Women’s issues
EAP	Mediation	Workplace issues
Early child development	Medical conditions	Other
Eating disorders	Men’s issues	Other

Practice Setting:

Work Schedule: Days Evenings Saturdays

Board Approved Supervisor

Consultation Services:

Educational Topics (250 character limit)

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