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CCC Member Profile Example Template
CCC Member Profile Example Template
Example Data of CCC member profile
Profile Photo
Accepted file types: jpg, gif, png, Max. file size: 250 MB.
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Name
First
Last
Email
Phone
Website
Offers Telehealth
yes
no
If so, in which states are you currently licensed in?
Offers In Person
yes
no
If yes, What locations
Accepting New Clients
yes
no
Accepting Referrals
yes
no
Currently Has a Waitlist for New Clients
yes
no
If yes, please enter your contact info
About
Clinician’s Sex/Gender
Male
Female
Practice Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Handicap Accessible?
yes
no
Days office open for appointments
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Select All
Practice Hours (show these options for each day)
List day and hours of Operation
Languages
List Languages, Example: English, Spanish, Chinese
I treat people of the following birth sex/gender
Male only
Female only
I comfortably treat both males and females
Select All
Treatment Services – member can choose multiple options
Psychiatric Evaluations (Psychiatrists or Nurse Practitioners)
Not Provided
60 min
75-90 min
120 min
How Long
Psychosocial Evaluations (Non-psychologist psychotherapists)
Not Provided
60 min
75-90 min
120 min
How Long
Psychological Evaluations (Psychologists)
Not Provided
60 min
75-90 min
120 min
How Long
Individual Sessions
Not Provided
50-60 min
Medication Management
0-15 min
20-30 min
45-60 min
How Long
Other Sessions
Couples Sessions
Family Sessions
Group Therapy
Telehealth
Legal/Court Forensic Evaluations
disability
custody
Other
other
Psychological Testing
yes
no
Ages
Toddler – Preschool (2-5)
Preteen (11-12)
Adolescent (13-17)
Adult (18-70)
Senior (70+)
Special populations
Vets
First Responders
Healthcare Workers
Pastors/Missionaries and their spouse/children
Ministry Leaders
Disabled
Pregnant
Ethnic Minorities
Other
Select All
other
Special populations
Types of Therapy
Talk Therapies
Psychodynamic
Cognitive Behavioral Therapy (CBT),
Emotionally Focused Therapy (EFT)
Rational Emotive Behavioral Therapy (REBT)
Dialectical Behavior Therapy (DBT),
Mindfulness
Meditation
Hypnotherapy
Acceptance and Commitment Therapy (ACT)
Eye Movement Desensitization Reprocessing (EMDR)
Interpersonal Therapy
Rapid Resolution Therapy (RRT)
Narrative Therapy
Positive Psychology Therapy
Attachment-based Therapy
Problem Focused Therapy
Solution Focused Brief Therapy (SFBT)
Family Systems Therapy
Gestalt Therapy
Motivational Interviewing
Trauma Focused
Internal Family Systems (IFS)
Strength-Based
Person-Centered
Relational
Eclectic
Interventions for unhealthy patterns of decisions/behaviors
Exposure Response Prevention (ERP)
Applied Behavioral Analysis (ABA)
Other (write in box)
Select All
other
Somatic Therapies
Medication Management
NeuroFeedback
Ketamine Therapy
Transcranial Magnetic Stimulation (TMS)
ECT
Vagus Nerve Stimulation (VNS)
Medication Assisted Therapy (MAT) – opioids, alcohol, benzodiazepines
Other (write in box)
other
Experiential Therapies
Art Therapy
Movement Therapy
Play Therapy
Sand Therapy
Music Therapy
Equine Therapy
Other Experiential (write in box)
other
Psychological Testing
yes
no
Treatment Issue
Top 5 Specialties
Abuse (childhood)
Abuse (current)
Addiction Chemical
Addiction Process (Behavioral)
ADHD
Adoption
Alcohol use
Alzheimer’s
Anger
Anxiety
Autism spectrum disorders
Behavioral issues
Behavioral issues
Bipolar disorder
Body Image Struggles
Borderline personality disorder
Career counseling
Chronic pain
Codependency
Cognitive Struggles
Depression
Dementia
Divorce
Domestic abuse
Dual Diagnosis
Eating disorders
Eating disorders
Education and learning disabilities
Employer Issues
Faith Struggles
Family Struggles
Gambling
Gender Confusion/Dysphoria/Dissonance/Incongruence (Biblical worldview)
Grief
Hoarding
Infertility
Infidelity
Intellectual disability
Internet addiction
Loss
Marriage Issues
Medical Issues – Acute or Chronic
Men’s issues
Moral Injury (MI)
Narcissistic personality disorder
Obesity
Obsessive compulsive disorder
Oppositional defiant disorder
Pain
Parenting/Children issues
Personality Disorders
Pregnancy, prenatal, postpartum
Process Addictions (Gambling, Spending, Hoarding, Exercise, Work, Productivity, Adrenaline, etc)
Psychoses
Racial identity
Relationship/Social Anxiety or Struggles
Resilience
Same Sex Attraction Struggles (Biblical Worldview)
Screen Addiction (Cell, Social Media, Gaming, TV, News Feeds, etc)
Self esteem
Self harm
Sex struggles/therapy
Sexual abuse
Sexual addiction
Sleep disorders or insomnia
Spiritual struggles
Sports performance
Stress
Substance abuse
Suicidal thoughts or urges
Trauma and Post Traumatic Stress Disorder (PTSD)
Traumatic brain injury (TBI)
Video game addiction
Weight loss
Women’s issues
Work Issues
Strengths – Pick up to 8
Abuse (childhood)
Abuse (current)
Addiction Chemical
Addiction Process (Behavioral)
ADHD
Adoption
Alcohol use
Alzheimer’s
Anger
Anxiety
Autism spectrum disorders
Behavioral issues
Behavioral issues
Bipolar disorder
Body Image Struggles
Borderline personality disorder
Career counseling
Chronic pain
Codependency
Cognitive Struggles
Depression
Dementia
Divorce
Domestic abuse
Dual Diagnosis
Eating disorders
Eating disorders
Education and learning disabilities
Employer Issues
Faith Struggles
Family Struggles
Gambling
Gender Confusion/Dysphoria/Dissonance/Incongruence (Biblical worldview)
Grief
Hoarding
Infertility
Infidelity
Intellectual disability
Internet addiction
Loss
Marriage Issues
Medical Issues – Acute or Chronic
Men’s issues
Moral Injury (MI)
Narcissistic personality disorder
Obesity
Obsessive compulsive disorder
Oppositional defiant disorder
Pain
Parenting/Children issues
Personality Disorders
Pregnancy, prenatal, postpartum
Process Addictions (Gambling, Spending, Hoarding, Exercise, Work, Productivity, Adrenaline, etc)
Psychoses
Racial identity
Relationship/Social Anxiety or Struggles
Resilience
Same Sex Attraction Struggles (Biblical Worldview)
Screen Addiction (Cell, Social Media, Gaming, TV, News Feeds, etc)
Self esteem
Self harm
Sex struggles/therapy
Sexual abuse
Sexual addiction
Sleep disorders or insomnia
Spiritual struggles
Sports performance
Stress
Substance abuse
Suicidal thoughts or urges
Trauma and Post Traumatic Stress Disorder (PTSD)
Traumatic brain injury (TBI)
Video game addiction
Weight loss
Women’s issues
Work Issues
List other Issues you treat
Do you agree with the AACC Doctrinal Statement
yes
no
Do you agree with the AACC Ethical Position
yes
no
Biblical Integration – Verbally integrating Biblical principles, passages, doctrines, stories, and information into your treatment session
yes
no
In 3-4 sentences, share how you integrate Biblical principles into your treatment with patients. Do you utilize homework’s assignments for patients to do in between sessions?
yes
no
What type of treatment approach do you utilize most frequently?
Patient led approach
Clinician led approach
Problem focused approach
Solution focused approach
In 3-4 sentences, share your approach when you are working with a patient.
How directive is your approach with patients?
I allow the patient to come up with their own interpretations and solutions
I share my insights, opinions, views and expertise with the patient
I share my insights, opinions, views and expertise with the patient even though they might be contrary to what the patient is thinking
I feel uncomfortable sharing my opinion, insights, and views with the patient
Photos of Office (Optional)
Accepted file types: jpg, gif, png, Max. file size: 250 MB.
Finances
Cost Per Session
Evaluations
50-60 min
75 -90 min
120 min
50-60 min Cost
75 -90 min Cost
120 min Cost
Individual Sessions
50-60 min
75 -90 min
50-60 min Cost
75 -90 min Cost
Couples Sessions
50-60 min
75-90 min
50-60 min Cost
75-90 min Cost
Group Sessions
50-60 min
90 min
50-60 min Cost
90 min Cost
Medication Management
15 min
30 min
60 min
15 min Cost
30 min Cost
60 min Cost
Other – box to add more services provided. Can add as many entries as needed)
Payment Methods Accepted
Cash,
Check
Credit Card
Venmo
Apple Pay
Zelle
other (list the online option)
Other form of Payments
Accepted Insurance Plans
Aetna
Cigna
Horizon
Anthem
Blue Cross
UnitedHealthcare
Optum
Kaiser
UPMC
Centrene
Highmark
Humana
GEHA
TriCare
Beacon
UMR
Molina
Medicare
Medicaid
Other (with write in box for multiple options.)
Other options
Sliding Scale
yes
no
Do you accept payment plans
yes
no
Do you provide or work with an organization that provides loans for treatment
yes
no
Qualifications
Years in Practice
License Number
DEA
Malpractice Insurance
Board Certifications
DEA Number
Malpractice Insurance Number
Board Certifications Number
School
Undergrad
Graduate School
Residency
Year Graduated
MM slash DD slash YYYY
Certifications
please separate with comma
Professional Associations
AACC
American Psychiatric Association
American Psychological Association
National Association of Social Workers
American Association of Marriage and Family Therapy
American Mental Health Counselors Association
Christian Association for Psychological Studies
North American Association of Christians in Social Work
Association of Christians in Health and Human Services
Other (Box to list multiple options)
Other (list multiple options)
