Referral Database Mental Health Professionals

The Oklahoma Mental Health Network (OMHN) is a comprehensive network of all mental health services and resources across the state of Oklahoma including adjunctive situations such as domestic violence, developmental disabilities, and family needs. This form asks basic questions about your services relevant to pediatric mental health. The intended use of this information is to provide a referral network for the Oklahoma Child and Adolescent Psychiatry and Mental Health Access Program (OKCAPMAP) to assist pediatric serving (0-21 years old) primary care providers across the state with successful referrals to therapeutic services and supports. This survey is for licensed mental health professionals. Please only complete this survey as a licensed mental health professional.

Thank you for taking the time to complete this survey and for helping bridge the gap in pediatric mental health care in Oklahoma.

Mental Health Provider

Thank you for answering these questions as a licensed mental health provider in the state of Oklahoma. Your answers will facilitate successful assistance with referral options for pediatric patients in an effort to match needs with therapeutic expertise and appropriate resources. Thank you!

Are you currently practicing?(Required)

Yes - in outpatient mental health

Yes - in inpatient mental health

Yes - in crisis or urgent recovery

Yes - in administration

No - I am either retired, working in another field or state, or not working.

Name of your practice location (name of your primary practice location)(Required)

Name of your second practice location (name of your second practice location)

Name of your third practice location (name of your third practice location)

Do you offer tele-therapy?(Required)

Yes

What is your first name?(Required)

What is your last name?(Required)

What is your race and/or ethnicity?(Required)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic/Latin(a/o)

Burmese

Zomi

Other

Other race and/or ethnicity

What non-english languages are you fluent in?(Required)

ASL

Spanish

French

Vietnamese

Native or First American Language

Chinese Cantonese

Chinese Mandarin

German

None or N/A

Other

Other non-english languages

What is your NPI #? (must be a 10 digit number)(Required)

What are your credentials and license to practice?(Required)

LPC – Licensed Professional Counselor

LMFT – Licensed Marriage and Family Therapist

LCSW – Licensed Clinical Social Worker

LMSW – Licensed Masters Social Worker

LADC – Licensed Alcohol and Drug Counselor

PsyD – Doctor of Psychology

PhD – Doctor of Philosophy

DO – Doctor of Osteopathy

MD - Medical Doctor

Other

Other provider credentials and/or license

What is your phone number?(Required)

What is your email?(Required)

What three populations do you have the most therapeutic experience with? (Pick a maximum of 3.)(Required)

LGBTQAI+

Hispanic/Latin(o/a)

Black or African American

Asian or Asian American

Native American/First Nations

Non-English speaking

Hearing impaired

Sight impaired

Physical disability

Developmental/Intellectual disability

None or N/A

Other

Other populations you have therapeutic experience with (e.g., refugee, immigrant, veteran/service member, medically complex)

What three age ranges (in years) do you have the most therapeutic experience with or preference to work with? (Pick a maximum of 3.)(Required)

0-3

4-6

7-11

12-16

17-18

19-21

What are the seven diagnoses you have the most therapeutic experience with or preference to work with? (Pick a maximum of 7.)(Required)

Adjustment disorder

Generalized anxiety disorder

Separation anxiety disorder

Social anxiety disorder

Phobia

Panic disorder

Reactive attachment disorder

Disinhibited social engagement disorder

Attention deficit hyperactivity disorder

Autism spectrum disorder

Anorexia nervosa/Bulimia nervosa

Avoidant restrictive food intake disorder

Bipolar disorder

Delirium

Depressive disorder

Oppositional defiant disorder

Conduct disorder

Impulse control disorder

Intellectual disability

Intermittent explosive disorder

Dissociative disorder

Enuresis/encopresis

Communication disorder

Mood disorders (other)

Tic disorder/Tourette syndrome

Obsessive compulsive disorder

Trichotillomania

Body dysmorphic disorder

Personality disorders

Post traumatic or acute stress disorder

Schizophrenia spectrum and other psychotic disorders

Sexual dysfunctions

Substance use disorders (i.e., alcohol, cannabis, nicotine, opiate)

Do you treat dual diagnoses?(Required)

Yes

No or N/A

If you treat dual diagnoses (e.g., ID/DD and mental health, chronic health condition and MHD), what dual diagnoses do you treat?(Required)

What evidence-based therapy modalities are you certified in? (Please select only the modalities you're fully certified in.)(Required)

PCIT – Parent-Child Interaction Therapy

EMDR – Eye Movement Desensitization and Reprocessing

CPT – Cognitive Processing Therapy

ACT – Acceptance and Commitment Therapy

ERP – Exposure and Response Prevention

CBT – Cognitive Behavior Therapy

DBT-C – Dialectical Behavior Therapy - Children

TF-CBT – Trauma-Focused Cognitive Behavior Therapy

CPP – Child Parent Psychotherapy

FFT – Family Focused Therapy

SFBT - Solutions Focused Brief Therapy

FST - Family Systems Trauma

BSFT – Brief Solutions Family Therapy

FCT - Family Centered Therapy

EFFT - Emotion- Focused Family Therapy

ABC – Attachment and Biobehavioral Catch-up

ABA - Applied Behavior Analysis

Play Therapy

None or N/A

Other

Other modalities you are certified in

What evidence-based therapy modalities do you have supervised training in? (Please select only the modalities you have received both training and supervision in.)(Required)

PCIT – Parent-Child Interaction Therapy

EMDR – Eye Movement Desensitization and Reprocessing

CPT – Cognitive Processing Therapy

ACT – Acceptance and Commitment Therapy

ERP – Exposure and Response Prevention

CBT – Cognitive Behavior Therapy

DBT-C – Dialectical Behavior Therapy - Children

TF-CBT – Trauma-Focused Cognitive Behavior Therapy

CPP – Child Parent Psychotherapy

FFT – Family Focused Therapy

SFBT - Solutions Focused Brief Therapy

FST - Family Systems Trauma

BSFT – Brief Solutions Family Therapy

FCT - Family Centered Therapy

EFFT - Emotion- Focused Family Therapy

ABC – Attachment and Biobehavioral Catch-up

ABA - Applied Behavior Analysis

Play Therapy

None or N/A

Other

Other modalities you have supervised training in

Are there any additional modalities you are trained in but are neither certified nor received supervision? (Please select only the therapy modalities you have received training for but have not received further supervision or credentialing.)(Required)

PCIT – Parent-Child Interaction Therapy

EMDR – Eye Movement Desensitization and Reprocessing

CPT – Cognitive Processing Therapy

ACT – Acceptance and Commitment Therapy

ERP – Exposure and Response Prevention

CBT – Cognitive Behavior Therapy

DBT-C – Dialectical Behavior Therapy - Children

TF-CBT – Trauma-Focused Cognitive Behavior Therapy

CPP – Child Parent Psychotherapy

FFT – Family Focused Therapy

SFBT - Solutions Focused Brief Therapy

FST - Family Systems Trauma

BSFT – Brief Solutions Family Therapy

FCT - Family Centered Therapy

EFFT - Emotion- Focused Family Therapy

ABC – Attachment and Biobehavioral Catch-up

ABA - Applied Behavior Analysis

Play Therapy

None or N/A

Other

Other modalities you are trained in but are neither certified nor received supervision

Do you have any special credentials or certifications? (Please select all that credentials or certifications you currently hold.)(Required)

ADTR – Academy of Dance Therapist Registered

ATR – Registered Art Therapist

BCBA – Board Certified Behavior Analyst

BCBA-D – Board Certified Behavior Analyst – Doctor

CCMHC – Certified Clinical Mental Health Counselor

CEDS – Certified Eating Disorder Specialist

CSAC – Certified Substance Abuse Counselor

ECMH-E – Early Childhood Mental Health - Endorsed

IMH-E – Infant Mental Health - Endorsed

MAC – Master Addiction Counselor

MT-BC – Music Therapist-Board Certified

NCPsyA – Nationally Psychoanalyst

NCC – National Certified Counselor

NCSC – National Certified School Counselor

RPT – Registered Play Therapist

None or N/A

Other

Other special credentials or certifications(Required)

If you have a specific faith, spiritual, or cultural approach to therapy, please describe. If you do not, type "none".(Required)

If you have any testimonials or endorsements for your work with specific diagnoses, modalities, populations, or ages, please share. If you do not, type "none". (Please do not include the person's name. If you do not have one, please type in "none".)(Required)