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Listing Form

Note: Yellow fields must be completed. White fields are optional.

		Your Field:

What word best describes your discipline?

Is there another title for your discipline that you would prefer to be listed under?

Education:

Registration (if this applies to you): (For legally regulated professions only)		Indicate registration body and number... Check here if this does not apply

Affiliations:		e.g., United Anthropologists of Idaho, Canadian Psychological Association, ...

Languages spoken:		English



		Your personal and contact information:

Salutation:

Last Name:

First Name:

Job Title:

Organization:

Address Line One:

Address Line Two:

City:

Province/State:

Postal/Zip code:

Primary Telephone:		e.g., (123) 456-7890
Secondary Telephone:
Cellular Telephone:
Fax:

Primary Email:		e.g., auntiesocial@prosocialscience.org
Secondary Email:

Web Site:		e.g., http://www.yourwebsite.com


		Introduction and services provided:

About Me: (Optional)		Example: After twenty years of providing social work services overseas, I was constantly amazed at how much work remains to be done in sensitizing new social workers to... Introduce yourself, your background (1000 characters or less)

Describe the workshops, seminars, presentations you would like to make available: (Optional)		Example: I particularly enjoy providing 1.5 to 2 hour workshops on the topic of "Vicarious Trauma", "Treating PTSD", and "Detection of Malingering". I can provide presentations on several other topics related to the above, to suit the needs of any given conference. Give titles for workshops/presentations if you have them.

Describe all services you have a preference for providing (and are lawfully qualified to offer):		Example: EMDR, Motivational counseling, Couples counseling, Social skills training for developmentally handicapped children, ...

Preferred client populations (if appropriate):		Example: Children, Adolescents, Adults, Adult Males, Elderly Women, Young male offenders, Professional educators, Ex-servicewomen, etc.

Keywords: Carefully chosen keywords will make you easier to find. (keywords only, separated by a comma)		Example: Psychopathy, Attitudes, Gerontology, Gender, etc.

Please be certain that the information you have entered is accurate and conforms to the laws of the jurisdictions that apply to you. By pressing the "Submit" button below, you acknowledge that you, and not Prosocial Science, are responsible for the accuracy of the information presented.