Request for Therapist Information from The ACONE Mental Health Services Directory

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Name of person or agency/organization requesting information

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Address to which to mail the response

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City, State and Zip

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Phone Number

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E-mail Address

Towns or cities to which you would travel for the services:

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Check the area(s) of expertise which you are interested in finding:

__ Abandonment
__ ADD/ADHD
__ Addiction problems
__ Adolescence
__ Adoption
__ Adoption disruption
__ Adult adoptee
__ Anxiety
__ Attachment
__ Behavior disorders
__ Birth parent
__ Depression

__ Eating disorders
__ Emotional abuse
__ FAE/FAS
__ Grief
__ HIV/AIDS
__ Holding therapy
__ Identity issues
__ Infertility issues
__ Kinship families
__ Latency age
__ Learning disabilities
__ Physical abuse

__ Pre-adopt
__ Pre-school age
__ Post-traumatic stress
__ Relative adoptions
__ Ritualistic abuse
__ Search/reunion
__ Separation and loss
__ Sexual abuse
__ Substance abuse
__ Suicide prevention
__ Transracial/transcultural
__ Other (please describe)
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Processing Fees:
_____ $10 ACONE member
_____ $25 nonmember
_____ Payment by check
_____ Visa/Mastercard/Discover

#_______________________________Exp. _______

3 digit # on back of card _______

Name and billing address (if different from above):

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Mail payment to: ACONE, Inc., 45 Lyman Street #2, Westborough, MA 01581.

Requests charged on MasterCard, Visa or Discover may be faxed to us at 508.366.6813.

Up to seven therapists' information will be sent as a response. If more than seven therapists fit your request profile, the seven closest to you geographically will be sent to you and you will be told that there are additional therapists which match your request. If the first seven therapists who fit your request profile do not meet your needs in other ways, you may request information on the other therapists who fit your request profile at no additional fee.