Honorific== select == Mr. Ms. Miss Mrs. M. Mme. Dr. Hon.
First Name
Last Name
Title/Position
Organization
Address
City
Prov/State== select == ==Canada== AB BC MB NB NL NS NT NU ON PE QC SK YT ==USA== AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MR MS MT NC ND NE NH NJ NM NN NV NY OH OK OR PA PL PO PR RI SC SD TN TT TX UT VA VI VT WA WI WV WY ==International== Other
Postal/Zip Code
Country== select == Canada United States --- 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 Bosnia and Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe
Phone
Home Phone (visible to admin only)
E-mail
Website
Clinic Practise (NOTE: Clinical CPSO CPD Membership requires practising a minimum of 51% Psychotherapy, Mental Health and/or Addictions)
Clinical Practice== select == 50-80% Psychotherapy / Mental Health Care 80-100% Psychotherapy / Primary Mental Health Care Other:
Designations (i.e., BSc, MD, MDPAC(C), etc.)
How did you hear about MDPAC? (select all that apply) Booth at CPA/Primary Care Conference Colleague Social Media Website
Other Reference
Therapy Provided Accellerated Experiential Dynamic Psychotherapy Acceptance and Commitment Therapy Adlerian Clinical Hypnotherapy Cognitive Behavioural Therapy Cognitive Meditation Therapy Compulsive Sexual Behaviours Couples Therapy Developmental Needs Meeting Strategies Eye Movement Desensitization and Reprocessing Therapy General Psychotherapy Gestalt Therapy Internal Family Systems Interpersonal Psychotherapy Mindfulness Based Therapies Neuro-Linguistic Programming Psychoanalytic Psychotherapy Satir Therapy Schema Focused Sex Therapy Sexual Orientation and Gender Identity Transaction Analysis
Other Therapy Provided
Special Interests ADHD Addictions Anxiety Disorder Borderline Personality Disorder Chronic Illness Dissociative Disorders Eating Disorders Eclectic Grief Mood Disorders Palliative Care Personality Disorders Stress Management Trauma/Abuse
Special Interests Other
Modes of Therapy Individual Therapy Couples Therapy Group Therapy
Medical School
Graduation Date
Please check off additional languages in which you provide psychotherapy service (check all that apply) French Arabic Cantonese Dutch German Greek Hebrew Hindi Italian Japanese Korean Mandarin Polish Portuguese Punjabi Russian Spanish Tagalog Ukrainian Urdu Vietnamese
Please describe your approach for potential patients
Are you licensed to practice medicine in Canada Y N
Please indicate the provinces/territories where you hold a license to practice medicine AB BC MB NB NL NS NT NU ON PE QC SK YT
License #
If you belong to the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada you can use them to report your Continuing Professional Development (CPD) or educational credits to the College of Physicians and Surgeons – only one pathway is required.
I belong to the Royal College of Physicians and Surgeons of Canada (RCPSC) Y N
I plan to report my CPD to the CPSO through the RCPSC Y N
I belong to the College of Family Physicians of Canada (CFPC) Y N
I plan to report my CPD to the CPSO through the CFPC Y N
If you do not belong to the RCPSC or the CFPC, do you wish to use the MDPAC as your Pathway to report your educational credits to the CPSO? Y N
CPSO Consent I give consent for the MDPAC to give the CPSO any information about my CPD that the CPSO requires, to show them that I have fulfilled the necessary requirements. I understand that this consent will remain in effect unless or until I withdraw this consent in writing. I also understand that I am required to be a Clinical CPSO/CPD, Certificant or Mentor member of the MDPAC in good standing for every year of the cycle for which a report is made. I understand I need to fulfill the requirements as determined by the MDPAC to complete the 3 year cycle.
Are you currently under investigation or do you have a complaint on file by your provincial licensing body? Y N
Please indicate your availability for accepting new patients== select == Accepting new referrals and/or self-referrals Waiting list available Not currently taking patients
Are your fees covered by public insurance?== select == Covered by Public Insurance Not Covered by Public Insurance
I grant MDPAC permission to sell my data for marketing purposes Y N
Do you consent to receive email communications from us? Y N
Do you want to join the general membership ListServ? (Please note: it takes up to 24 hours to get added to the ListServ) Y N
Show my email on the public find a physician who practices psychotherapy directory Y N
In an effort to be environmentally conscious, MDPAC would like you to consider receiving your MDPAC Journal electronically. Yes, please send me MDPAC Journal electronically.
This signature verifies that the information submitted above is accurate. (Type your name)
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