Professional Referral Resource Profile Form

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 Recovery Ways Treatment Centers. You can also use this form to update your information with Recovery Ways.
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:
Fax:
Website:

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

Population Served:
	18 and Above	Geriatric
	Adolescents	GLBT
	Children under 16	Men Only
	Couples	Women Only
	Families

Insurance:
	Takes Insurance	Cigna
	Aetna	Medicaid
	BC/BS	Other
	Private Pay	IHC
	UBH	Medicare

Specialization (please check all that apply):
	ADD/ADHD	Dual Diagnosis
	Meditation	Rapid Detox
	Alanon	Eating Disorders
	Methadone Maintenance	Recreational Therapy
	Alumni Program	EMDR
	Neuro Feedback	Relapse Prevention
	Anger Management	Equine Therapy
	Nicotine Cessation	Self Abuse/Self Harm
	Anxiety	Female Issues
	Nutritional Guidance	Sex Addiction
	Art Therapy	Fitness Program
	OCD	Sexual Abuse/Rape
	Bi Polar	Gestalt Techniques
	Parenting Skills	Somatic Therapy
	Bio Feedback	Gambling Addiction
	Pain Mgmt	Sleeping Disorder
	Co-Dependency	Grief/Loss
	Personality Disorder	Spiritual Counseling
	Cognitive Behavioral Therapy	HIV Counseling
	Process Group	Stag Group
	DBT	Learning Disabilities
	Psychotherapy	Trauma
	Depression	Holistic Approach
	Psychiatric Services	Steroid Abuse
	Detox	Hypnotherapy
	Psychodrama	Substance Abuse Specialist
	Drug & Alcohol Testing	Life Skills Coaching
	PTSD	Violence/Physical Abuse
	Drug Education	Med Management


Groups Description:
Time:
Days:
Cost:
Workshops Description:
Time:
Days:
Cost:
Your Sober Birthday (Optional):
Your Birthday (Optional):
Comment:

Code:

What are they saying about
Recovery Ways?

"I wanted everyone to know that I will have a year of sobriety in October. I am enrolled in a University and made the dean's list with a 4.0 GPA. I never thought this was possible. I know you will keep touching lives like you have touched mine. THANKS"

James May - Cleveland , OH