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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 ________________________ (required)

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 $70 for the basic private practice listing and $41 additional to include an optional "niche specialty" listing.  These fees are for initial set-up and are not refundable once the listing has been published. 

Basic Listing Set-Up Fee ......................  $  70.00
[optional "niche specialty" listing $41]*     + _____
                                          Total cost     $ _____

Your listing on CounselingSeattle.com will give you a credit balance for one year.  After that year, you will billed monthly $8.98 to your credit card.  Be alert for a notice that the automation of advertising section of the site has been completed.  At that time, you will be asked to go to the first page of the site (upper right hand corner of the page) to log in and set up an account with CounselingSeattle.com.  This will give you the freedom to enter the site in the future to change things such as your telephone number, office address, mailing address, etc.  Once the new system is in place, counselors will be listed in order of the day they logged in and set up their account.  Even though you may enter payment information at that time, your credit card will not be charged until your first year is up. 

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.

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