Clinician Supervisor(demongraphics questionnaire)

Pre-Test of Instruments of Psychosocial Care for the Treatment of Adults with PTSD

20987 ID_Clinician and Supervisor Demographics Questionnaire-ATTACHMENT 6

Clinician Supervisor(demongraphics questionnaire)

OMB: 0990-0418

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ATTACHMENT 6

DEMOGRAPHICS QUESTIONNAIRE



Thank you for registering your user name for the Pre-Test of Instruments of Psychosocial Care for the Treatment of Adults with PTSD. Your participation is greatly appreciated.



Please take a moment to complete your profile and answers these brief questions below.



Clinician Characteristics

  1. How many months/years have you been providing therapy?

Fill in blank and circle correct option:

____ Months/ Years

  1. How many months/years have you been treating individuals diagnosed with PTSD?

Fill in blank and circle correct option:

____ Months/ Years

  1. Are you currently licensed as psychiatrist, clinician, counselor or social worker?

Circle correct option:

Yes/No

  1. What is your degree?

Circle correct option. MS/MSW/MA/PhD/PsyD/MD/Other

If other, please specify _______________


  1. What is your treatment orientation?

Circle correct option(s):


    1. CPT

    2. PE

    3. Psychodynamic

    4. EMDR

    5. Psychoanalytic

    6. Supportive

    7. Bio feedback

    8. Interpersonal

    9. Other:

  1. Have you taken any accredited courses or certifications in Cognitive Behavior therapy?

Circle correct option:

Yes/No

  1. How many clients are you currently seeing?

Fill in blank:

­­­­_________


  1. How many clients are you currently seeing with the primary diagnosis of PTSD?

Fill in blank:

­­­­__________


  1. Are you currently licensed to provide mental health treatment in your state?

Circle correct option:

Yes/No






Thank you for your responses! Your site coordinator will be contacting you shortly with the details of your first survey!









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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDemographic characteristics Therapist
AuthorAlisa Ainbinder
File Modified0000-00-00
File Created2021-01-27

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