Allied Health Care - Mental Health Counselor / Therapy Services Supplement Allied Health Care – Mental Health Counselor : Therapy Services Supplement APP PDF Download Allied Health Care - Mental Health Counselor / Therapy Services Supplement 1) Name of Applicant:* Prefix First Last Suffix 2) Please indicate type of counseling services provided:* Art Therapy Dance Therapy Drama Therapy Guidance Counselor for Schools Horticultural Therapy Mental Heath Counseling Music Therapy Pastoral/Faith Based Counseling Pet/Animal Assisted Therapy Recreational Therapy Wellness Counseling Other:3) List primary types of disorders treated:*4) Does the applicant provide any form of recovered or repressed memory therapy?*YesNo5) Does the applicant specialize (greater than 25% of services provided is considered specialization) in treatment of any of the following?*YesNo Body disorder issues (Dysmorphic disorder, cutting, etc.) Forensic psychologist/counselor Suicide Counseling Eating disorder/obesity (for minors) Sexual abuse (physical abuse) Sexual Offenders 6) Percentage of practice involved with treating minors who are victims of molestation, abuse or violence?*10%20%30%40%50%60%70%80%90%100%7) Does the applicant provide suicide hotline service?*YesNo8) Does the applicant provide perpetrator counseling whether or not the perpetrator is charged with or convicted of a crime?*YesNo9) Does the applicant provide court appointed evaluations or counseling including counseling of person on probation or parole?*YesNo10) Does the applicant use hypnotherapy as a treatment modality?*YesNo11) Does the applicant use shock therapy as a treatment modality?*YesNo12) Does the applicant provide abortion counseling, adoption screening or foster care screening?*YesNo13) Does the applicant use animal assisted therapy treatment modalities?*YesNoa) Percentage of practice using Equine therapy?*10%20%30%40%50%60%70%80%90%100%b) Percentage of practice providing animal assisted treatment to minors?*10%20%30%40%50%60%70%80%90%100%14) If a school counselor, does the applicant develop safety or security plans or emergency preparedness programs for schools?*YesNoN/AThis supplemental application is incorporated into and is deemed a part of the other application(s) submitted in connection with the requested insurance. Any and all notices and representations included in such other application(s) are incorporated by reference in this supplemental application as though fully set forth herein.Name of Applicant:*(Please type full name in space provided)Title:*Applicant's Signature(Please use your mouse on a PC or Mac, or your finger or stylus on a tablet or smartphone to sign your name.)Date:* Date Format: MM slash DD slash YYYY Producer Name:*Retail Agency Name:*Agent's Signature:*(Required in New Hampshire) (Please use your mouse on a PC or Mac, or your finger or stylus on a tablet or smartphone to sign your name.)This document does not amend, extend or alter the coverage afforded by the policy. For a complete understanding of any insurance you purchase, you must first read your policy, declaration page and any endorsements and discuss them with your broker. A specimen policy is available from an agent of the company. Your actual policy conditions may be amended by endorsement or affected by state laws.NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.