[ rates at bottom of page ]  Counselor Listing Information Form
Advertise Your Private Practice on CounselingSeattle.com
Print out this page, complete, sign and mail it with your check to: Floyd Else, Webmaster, CounselingSeattle.com, PO Box 6714, Bellevue, WA 98008-0714   (425) 643-7434

First Name _______________________ Last Name __________________________

Mailing Address _______________________________________________________

City _____________________ State _____ ZIP ________ Highest Degree _______

Do you have a private practice?  Yes  No    If "Yes," complete address of your

private practice office: _________________________________ ZIP ____________
[if applicable]                                   [or]
Practice Name ____________________ Agency Name ________________________

Practice Phone (____) _____________ Agency Phone (____) __________________

Fax Number     (____) _____________  Email Address ________________________

Home Phone    (____) _____________  Website Address ______________________

General Areas of Practice: (client problems with which you commonly help
clients, therapeutic approaches, client types: children, adolescents, adults,
couples, groups.)
_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Professional License or Registration in the State of Washington:
                                       Registration/license
Type(s) __________________________ Number ____________________________
    (e.g., LMFT, LICSW, LMHC, RC)

RELEASE: I am requesting that information about my counseling private practice be listed on CounselingSeattle.com.  I understand that my email address is need for communication with the webmaster and will not be included in my listing, unless I specifically request it.  My home phone number is also only a back-up link for communication between myself and the webmaster. 

 
Signature __________________________________       Date _________________        

Fee Computation

The initial set-up fee is $60 for the basic private practice listing and $41 additional to include an optional "niche specialty" listing. 

Basic Listing Set-Up Fee ......................  $  60.00
[optional "niche specialty" listing $41]*     + _____
                                          Total cost     $ _____

Please complete the counselor information form, enclose your check--payable to Floyd Else--and mail to:

Floyd Else, Webmaster
CounselingSeattle.com
PO Box 6714
Bellevue, WA 98008-0714

[Please mark your check in the lower left hand corner: "for private practice advertisement."  Your cancelled check will serve as your receipt for accounting and tax purposes.]  You will receive an acknowledgement by email within three working days of receipt of the documents.

After you have been listed on CounselingSeattle.com for one year, you will be billed for an annual renewal fee of $55 to remain on the site. 

NOTICE: Rates are subject to change without notice.  Current rates will be published on this page.