Clinician Supervisor(demongraphics questionnaire)

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

How many months/years have you been providing therapy?	Fill in blank and circle correct option: ____ Months/ Years
How many months/years have you been treating individuals diagnosed with PTSD?	Fill in blank and circle correct option: ____ Months/ Years
Are you currently licensed as psychiatrist, clinician, counselor or social worker?	Circle correct option: Yes/No
What is your degree?	Circle correct option. MS/MSW/MA/PhD/PsyD/MD/Other If other, please specify _______________
What is your treatment orientation?	Circle correct option(s):
	CPT PE Psychodynamic EMDR Psychoanalytic Supportive Bio feedback Interpersonal Other:
Have you taken any accredited courses or certifications in Cognitive Behavior therapy?	Circle correct option: Yes/No
How many clients are you currently seeing?	Fill in blank: ­­­­_________
How many clients are you currently seeing with the primary diagnosis of PTSD?	Fill in blank: ­­­­__________
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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