The AFA Therapist Network Form

Name:

Professional Degree:

Primary Practice

Primary Practice Name:

Office Address:

City:

State:
AlabamaAlaska ArizonaArkansasCalifornia ColoradoConnecticut District of ColumbiaDelaware FloridaGeorgiaHawaii IdahoIllinoisIndiana IowaKansasKentucky LouisianaMaineMaryland MassachusettsMichiganMinnesota MississippiMissouriMontana NebraskaNevadaNew Hampshire New JerseyNew MexicoNew York North CarolinaNorth DakotaOhio OklahomaOregonPennsylvania Rhode IslandSouth Carolina South DakotaTennesseeTexas UtahVermontVirginia WashingtonWest VirginiaWisconsin WyomingAlbertaBritish Columbia ManitobaNew BrunswickNewfoundland Northwest TerritoriesNova Scotia NunavutOntario Prince Edward IslandQuebec SaskatchewanYukon

Zip:

Business Phone:

Business Fax:

Secondary Practice

Secondary Practice Name:

Office Address:

City:

State:
AlabamaAlaska ArizonaArkansasCalifornia ColoradoConnecticut District of ColumbiaDelaware FloridaGeorgiaHawaii IdahoIllinoisIndiana IowaKansasKentucky LouisianaMaineMaryland MassachusettsMichiganMinnesota MississippiMissouriMontana NebraskaNevadaNew Hampshire New JerseyNew MexicoNew York North CarolinaNorth DakotaOhio OklahomaOregonPennsylvania Rhode IslandSouth Carolina South DakotaTennesseeTexas UtahVermontVirginia WashingtonWest VirginiaWisconsin WyomingAlbertaBritish Columbia ManitobaNew BrunswickNewfoundland Northwest TerritoriesNova Scotia NunavutOntario Prince Edward IslandQuebec SaskatchewanYukon

Zip:

Business Phone:

Business Fax:

E-Mail:

Web Address:

Profession
Psychologist
Psychiatrist
Social Worker
Marital / Family Therapist
Psychiatric Nurse

College / University your Degree is from & Year:
1930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819892000200120022003200420052006200720082009

Post Degree & Year:
1930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819892000200120022003200420052006200720082009

Other Training and Year:
1930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819892000200120022003200420052006200720082009

License Information:
State licensed:

Year licensed:

License/Certificate number:

Social Workers enter NOT APPLICABLE if your state does not require licensure:

Do You carry Malpractice Insurance?
Yes No

Do You have any Malpractice decisions against you or pending?
Yes No

Select the GROUPS you work work
Individuals
Couples
Groups
Families

Specialty Area For Resource Directory Listing:
Please Check All That Apply To Your Specialties or Services Performed at Your Practice:
Early Menopause
Adoption
Alternative Medicine
Anxiety/Stress Management
Assisted Reproduction Technology
Cancer & Inftertility
Child Development
Couples Counseling
Depression
Early Menopause
Divorce
Egg & Sperm Donation
Egg Freezing
Ethical Issues
Family Planning
Foster Care
Gestational Carrier/Surrogacy
Grief Counseling
High Risk Pregnancy
Hormonal Disorders
Infertility
Infertility to Adoption Transition
Lesbian and Gay Issues
Male Factor Infertility
Mind/Body
Multiple Pregnancy
Over 40
Parenting After Infertility
PCOS
Postpartum Depression
Pre/Post Adoption Issues
Pregnancy After Infertility
Pregnancy Loss/Miscarriage
Preimplantation Genetic Diagnosis (PGD)
Recurrent Pregnancy Loss
Secondary Infertility
Sex Therapy
Sexual Dysfunction
Single Women
Talking to Children About Their Adoption
Talking to Children About Their Conception
Third Party Reproduction

Are You A Participant In Any Managed Care Plans?
No Yes <25% Yes 25% - 50% Yes >50%

Do You Treat Patients On A Fee-For-Services Basis?
Yes No

Other and Year:
1930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819892000200120022003200420052006200720082009

Professional Memberships:
Professional Member of The AFA
ASRM - Society for Assisted Reproductive Technology
ASRM - Society of Reproductive Surgeons
ASRM - Society of Reproductive Endocrinologists
ASRM - Society of Reproductive Urologists

Other Membership:

Other Membership:

Other Membership:

Acknowledgment:

I understand that my participation in the AFA Therapist Network is voluntary and that my inclusion or removal from the Network is at the AFAÕs sole discretion.

I agree to respond to any referral generated from the AFA Therapist Network in a timely and ethical fashion. I understand that inclusion in this network in no way implies that AFA is an accrediting agency. Furthermore, I can attest that there is no disciplinary action pending against me as a practicing professional.

In consideration of my inclusion in this network, I agree to indemnify, defend and hold the AFA harmless in the event a patient referred to me by the AFA makes a claim against the AFA, its directors, employees, members, and volunteers in connection with services rendered by me.

Please enclose your resume/curriculum vitae and a copy of both your professional license and malpractice cover sheet with the form and send to:

Joann P. Galst, Ph.D.
30 E. 60th Street
Suite 802
New York, NY 10022