PROFESSIONAL MEMBERSHIP FORM

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Areas of Interest:
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Ongoing Treatment:

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Handicapped Accesible(YES/NO):

Accepts:

Managed Care (YES/NO):

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Medicare (YES/NO):

Medicaid (YES/NO):

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Florida Health Care(YES/NO):

 
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                                                          Professional Members Questionnaire

Would you be willing to offer pro bono services to a referral from the MHASWFL for up to four sessions? YES NO

Would you be interested in participating in the MHASWFL CEU Program?  YES NO
Please list topics of interest:


Would you be willing to join the MHASWFL Speakers Bureau? YES NO
Please list topics of Presentations:


Would you be willing to teach Putting Children First court mandated divorce education program provided by MHASWFL? YES NO

Would you be interested in facilitating support groups for MHASWFL? YES NO
Please list areas of Interest:


Would you write articles for our newsletter?  YES NO
Please List areas of interest:


We value your opinion on how we are doing, what can we improve, and what would
you like to see in the future?