Specialty Form Updated 04/05/17

MODA HEALTH BEHAVIORAL HEALTH SPECIALITIES

Provider Name: Provider NPI #:

Patient Age Groups: 6 and under: 7 -12: 13 – 17: 18 – 64: 65 and up:

Languages other than English:

Office hours: Evenings?: Weekends?:

Your Race/Ethnic Group (Optional): This information is used to meet the referral requests of clients.

Please check the boxes for clinical expertise/specialty training

ABA Therapy Home VisitsADD/ADHD Impulse Control Disorders Adjustment Disorders Internet AddictionAdoption LGBTQAIDS/ARC/HIV (co-morbid) Medication ManagementAnger Management Men’s IssuesAnxiety Disorders Neuro-Psychological TestingAttachment Disorders OCDAutism Spectrum Disorder Oppositional DefianceBi-Polar Disorder Pain Management CBT Panic AttacksChemical Dependency Parenting Chronic Physical Illness Personality DisordersCo-dependency PhobiasConduct Disorder Physical Abuse VictimsCoping Skills Play TherapyCouples/Marriage Counseling * PostpartumDBT Psychological Testing * Depression Psychotic DisordersDevelopmental Disabilities PTSD/TraumaDissociative Disorders Relationship *Divorce Adjustment Religious Orientation-Identify: Domestic Violence/Abuse Offenders Sex OffendersDomestic Violence/Abuse Victims Sexual Assault Victims (Rape)Dual-Diagnosis Sexual Abuse VictimsEating Disorders Sexual AddictionECT Sleep DisordersEMDR Solution Focused TherapyExposure and response prevention Somatoform DisordersFactitious Disorders Stress ManagementFamily Counseling * TelemedicineFibromyalgia (co-morbid) VeteransFirst Responders Video Gaming AddictionForensics Violent Crime VictimsGambling Women’s IssuesGrief/Loss Work IssuesGroup Counseling OtherHoarding Other:

*Not covered in the absence of an individual diagnosis