You/ Your Organization’s Contact Information: (Required fields are marked with an *)

How did you hear about us?
* Therapist's Name:
* Credentials:
* Title:
* Organization:
* Street Address:
Address (cont.):
* City:
* State:
* Zip Code:
*  County:
* Contact Person:
* Telephone Number:
Fax Number:
* Email Address:
Web Address:
Services You/ Your Organization Provides:
Type of Service(s)Provided:
Age Range of Clients You Provide Services To:
Specialties:
Training/Education in Adoption, Children with Special Needs, Parenting or Issues Related to Your Specialty:
Professional/Personal Experience with Adoption, Children with Special Needs, Parenting, or Issues Related to Your Specialty:
Insurance Payment Options:
Do you accept Medicaid?
Do you accept other insurance? Please specify:
Do you accept private clients?  Please specify:
Other:  Information you would like to provide on the website / handbook (subject to editing) and/or any other information about your organization/ practice:
If you would like to delete or revise any of this information, please contact: NJARCH Resource Development Coordinator at (973) 763-2041 x 209 or Fax us your update at (973)378-9575 or E-mail us at surveyupdate@njarch.org