This application should be completed by the e-therapist,
not by a web developer or other person.

The information in this box is required:

Check one: This is a new application   This is an update E-Therapist name: If your website has not launched yet, please do not fill out this form. E-Therapy website title: E-Therapy website URL: Contact information, so we can reach you if we have questions: Your e-mail address: Your phone number: Please check to make sure the information above is accurate.

You are not required to complete any other information on this page. However, if you do:

• you will vastly improve your rating
• your site will get listed much sooner
• you will be providing us with valuable statistical information about e-therapy

For the sake of expediency, we use the terms below in this application. We realize they are inexact, and beg your indulgence.

E-Therapy: the services you are providing via the Internet
E-Therapist: you, the therapist providing services via the Internet
E-Patients: the people you are helping via the Internet
E-Session: one interaction with your e-patient: e-mail exchange, chat session, etc.

1. What is your primary professional discipline?
   Psychologist
   AAPC-Certified Pastoral Counselor
   Social Worker
   Marriage-Family Therapist
   Licensed Professional Counselor
   Psychiatrist
   Psychoanalyst
   Other:

2. Where is your regular practice located?
   City
   State/Province    Country

3. List up to three of your relevant professional credentials in mental health (license, certification, or registration). To qualify for a rating, you must list at least one. Please help us with acronyms: provide the abbreviation (if relevant) and spell it out for us.
   Do not list academic degrees here.
   A credential is issued by a government agency or profesional organization, to which you have an ongoing accountability, that has reviewed your academic qualifications, post-graduate therapeutic training and experience, and pronounces you qualified to practice psychotherapy.

4. Are you covered by professional liability (malpractice) insurance?
   Yes
   No

5. Have you completed a supervised clinical training program in general psychotherapy?
   Yes, during my master's/doctorate degree.
   Yes, separately from my master's/doctorate.
   No, I did not complete supervised clinical training in psychotherapy.

6. How many hours of supervised clinical training in psychotherapy were required for you to qualify for the primary credential listed in #3 above?

7. Your highest relevant academic degree (master's or doctorate):

   Abbreviation:
   Write it out:
   Year:
   Subject:
   University:
   Location:
   Telephone number:
   		If we will need additional information to be able to verify your degree, such as your maiden name or student ID number, please provide it:

8. If your primary training in psychotherapy was not through a degree-granting institution (for instance a counseling training program or psychoanalytic training institute) please describe:

   Program:
   Year:
   Subject:
   Institution:
   Location:
   Telephone number:

9. How much of the following information is available to the public on your website? (i.e. a prospective patient has access to this information without having to contact you first)
   Your real name (first and last)
   State and country where you practice
   City where you practice
   Professional office telephone number
   Verifiable details of your mental health credentials

10. How many professional psychotherapists offer services through your website?

11. If more than one, can a prospective e-patient choose in advance which therapist they will work with? yes   no   n/a, only 1 therapist

12. When a prospective e-patient contacts you from your website, do you provide a personal, individual, private response? Always   Sometimes   No

13. On your site do you promise to respond to an initial inquiry from a prospective e-patient within a certain amount of time? yes   no    If yes, how long?

14. What one-to-one private communication modes do you offer for interactions with e-patients?
    

    Check modes you offer:		Do you offer security/encryption for this mode?
    e-mail		yes   no   don't know
    private chat		yes   no   don't know
    web messaging		yes   no   don't know
    videoconferencing		yes   no   don't know
    internet phone		yes   no   don't know

15. How do you interact with e-patients?
    An ongoing series of conversations over time
    I prefer ongoing conversations, but I sometimes answer a single question
    I prefer to answer a single question, but I sometimes do ongoing conversations
    I will only answer a single question

16. What kinds of problems do you offer help for via the Internet?
    General practice - I work with most kinds of problems
    Specialty - I work only with a specific kind of problem (specify:)
           

17. Are there any problems you will NOT work with via the Internet?
    
    Is this clearly stated on your website? Yes   Unsure   No

18. Before you work with e-patients on the Internet, do you require that they first contact you:
    by telephone   in person   neither

19. On your website, do you provide prospective e-patients with information about the limits of confidentiality of Internet communications? Yes   Unsure   No

20. Do prospective e-patients have access to clear information about the amount of your fees in advance, before they decide whether to contact you? Yes   Unsure   No

21. Can a prospective e-patient reading your website determine exactly how much their first e-session will cost, before contacting you? Yes   Unsure   No

22. Before they can contact you the first time, do you require a prospective e-patient to:
    pay in advance   submit credit card number in advance

23. What forms of payment do you accept?
    Visa/MasterCard: submitted by   secure web page   fax   phone   other
    Other credit card: submitted by   secure web page   fax   phone   other
    Electronic checks: submitted by   secure web page   fax   phone   other
    Check or money order sent by postal mail
    Telephone billing (charge to e-patient's phone bill)
    PayPal
    Other:

24. How do you generally charge for e-sessions (i.e., chats, e-mail exchanges etc.):
    flat charge per e-session   by the hour (or minute)

25. If you work primarily in live chat or videoconference sessions, how long are your typical e-sessions?

26. If you charge by the hour or minute for time you spend reading and composing messages asynchronously (other than chat), is there a "cap" or maximum amount you will charge per e-session?
    Yes   No   I don't charge by the hour/minute

27. Please describe your e-therapy rates and fees. The more forthcoming you are about your rates, the happier we are. Please include all the following information:
    • How much you charge for e-sessions
    • How much you charge for the initial e-session, if different
    • How much a prospective e-patient must pay in advance before they can contact you
    • If an e-patient must pay in advance for several e-sessions, how much and how many
    • If you have any "deals" available (i.e. "one month unlimited e-mails for $")
      

28. Is all of the information you entered in the questions above available to prospective e-patients on your site in advance, before they decide whether or not to contact you for the first time?
    yes, all of it
    nearly all of it
    some of it
    none of it
    If some of the information is not available to prospective e-patients on your site in advance of their first contact, please explain what and why:
    

29. Do you require prospective e-patients to "sign" a consent form as part of their initial contact? Yes   No

30. For e-sessions, do you usually access the Internet from a computer in your:
    therapy office   home   other

31. In addition to yourself, how many other people have access to the computer you use for communication with e-patients?

32. In addition to yourself, who else has access to personal information about your e-patients?

33. Do you store communications with or personal information about e-patients on floppy disks or other removable media? Yes   No
    If yes, are those disks kept under lock and key? Yes   No

34. Do you ever make printouts of communications with e-patients? Yes   No

35. Do you ever make printouts of personal information about e-patients? Yes   No

    
    

    The following information does not affect your rating; it is helping us compile important statistics about e-therapy. Thank you for answering these questions:

36. What date did your e-therapy website officially launch?

37. As of today, how many "e-patients" have you worked with?

38. On the average, how many "e-sessions" (e-mail exchanges, chats etc.) do you have with e-patients from start to finish of their relationship with you?

39. What information do you ask e-patients to submit in their initial contact?

    		I ask, but don't require an answer		I require an answer		I don't ask
    real first/last name
    physical address
    telephone number
    medication status
    therapy history
    if they are suicidal

40. Before contacting you on the Internet, estimate what percentage of your e-patients had previously been in traditional face-to-face therapy:
    % - had been in therapy with other therapists
    % - had been in therapy with you
    % - had never been in therapy
    don't know, or no patients yet

41. After working with you on the Internet, estimate what percentage of your e-patients subsequently went to traditional face-to-face therapy:
    % - after e-therapy, went to therapy with other therapists
    % - after e-therapy, went to therapy with you
    % - did not go to therapy, as far as you know
    don't know, or no patients yet

42. Estimate what percentage of your e-patients are physically located:
    % - in the same U.S. state as you
    % - in a different U.S. state from you
    % - in a different country from you
    % - in the same non-U.S. country as you
    don't know, or no patients yet

43. Generally, what are the most common problems e-patients are bringing to you?

44. In your opinion, why do most of your e-patients use the Internet to find help?

45. Would you ever be willing to talk with a reporter about your experiences as an e-therapist? yes   no   maybe

46. If you answered yes or maybe, please fill in your contact information again:
    Telephone number:
    E-mail address:
    We can't guarantee interviews by any means, but we are happy to put you on the list. You can also sign up for the ISMHO media list; we will send you that information by e-mail.

47. How long have you been using the Internet?
    0-6 months
    6-12 months
    1-3 years
    3-6 years
    over 6 years

48. Any other comments:

Before pressing the submit button, please review your application for accuracy. We will visit your website to verify your answers and complete your rating, and if possible we will make one or more phone calls to verify your credentials.

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