Language English Thank you for your interest in BMT InfoNet's Mental Health Directory for stem cell transplant and CAR T-cell recipients. Please provide the information requested in this brief survey below, After receiving your responses, we will contact you to schedule a short interview to understand your experience and expertise better. If you have any questions, please email us at help@bmtinfonet.org or phone 847-433-3313. First Name * Last Name * Please provide how you would like your organization to be listed * What are your professional degrees and licenses? In which states are you licensed to practice? * All StatesInternationalAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming In what year did you receive your professional license? Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074 Email * What Email Address may we publish in the directory for patients to use? Phone Number * What phone number may we publish for patients to use? Please provide a website address where patients can learn more about you. Please begin with http:// Street address should be the address where you see clients. Street Address Street Address Line 2 City State/Province Postal Code Areas of Expertise Type of Therapist Social workerPsychologistCounselor/TherapistNurse/Nurse PractitionerPsychiatristPsychiatric Nurse PractitionerPastoral CounselorOther Which diseases do you have experience in? Leukemia Lymphoma, Hodgkin Disease Multiple Myeloma Myelodysplasia, Myeloproliferative Disorders Inherited Disorders eg, Sickle Cell Disease, Thalassemia Please list any other disease you have experience with. Area of counseling experience Allogeneic bone marrow/stem cell transplantAutologous bone marrow/stem cell transplantCAR T-cell therapyGraft-versus-Host Disease For which stages of treatment can you provide patient support? Diagnosis and initial treatmentEarly recovery (first 24 months after treatment)Long-term survivorship (more than 2 years after treatment)RelapseSecondary cancersEnd of lifeGrief/bereavementNone of the above Age of Patients Accepted Children under 12Preteen/TeensYoung adults 18-35Adults 36-60Adults 60 and older Do you provide counseling for caregivers? Yes No What stages and severity of GVHD do you have experience with? All stages of GVHDGVHD during first 12 months after transplantGVHD 1-3 years after transplantGVHD that persists more than 3 years after transplantMild cases of GVHDModerate or severe GVHD with significant impact on quality of lifeNone of the above Other ares of expertise Anxiety/DepressionTrauma/PTSDPain managementStress management/ MindfulnessCognitive behavioral therapy for insomnia (CBT-I)Neurocognitive rehabilitationSexual healthCouples therapyFamily therapyParenting What type of fee structure do you offer? Services are free to patientsIn-network private insurance providerOut-of-network private insuranceMedicare providerMedicaid providerSelf PaySliding scale based on ability to payOther Other Payments? Where is service provided Medical center or clinicPrivate practiceOrganization Do you provide Telehealth services? Yes No Are you a member of PsyPact (Psychology Interjurisdictional Compact)? Yes No Please provide any additional experience you would like to share Would you be interested in more training about working with transplant and CAR T-cell patients? Yes No Leave this field blank Submit