Sex Addiction Training and Supervision Interest Survey
Your specific information is strictly confidential. Only composite statistics will be used in planning or research.
 
Your professional training:
Family Doctor
Psychologist
Counsellor
Addiction counsellor
Social Worker
Psychiatrist
EAP counsellor
Human Resources
 
Your role in addiction treatment:
Screening/referral
Medical care
Administration
Emergency care
Clinical Supervision of therapists
In-patient care
Assessment
Therapy
Education
Average length of session with client
15 minutes or less      One-half hour
One hour                  Other
                                     
Do you send clients to 12 step programs?
 Yes              No
Is your work setting a:
Public clinic               Private practice
Hospital                     Treatment center
Usual number of sessions you have for diagnosis/treatment with a client?
Have you thought that some of your clients/patients were addicted to sex before this presentation?          Yes    No
Do you think some may be addicted to sex after hearing this presentation?Yes No
 
Would you like to be part of a supervision group?      Yes    No
May we send you information about trainings?         Yes    No   
Do you want CEU'S?  Yes  No           Do you want certification?     Yes     No
 
Professional development opportunities you could use:
Half-day workshops     Full day workshops      A block of several
 Other:
Training/teaching modalities that suit your workplace setting.
Telehealth     Skype/video conferencing       Seminar      Video/DVD
Online/e-courses     Telephone supervision   Other
 
Please suggest frequencies that would work for you and your organization:
Weekly      Bi-weekly     Monthly     Yearly     On-going in some form
Other:
 
Your email:
Your telephone number: