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Name
Credentials (i.e., LCSW, CADC, CIP):
In what year did you obtain your CIP?:
How many years have you been performing professional interventions?:
< 1
1-2
2-5
5-10
10-20
20 plus
Name of Intervention Company (cannot be a treatment center):
City & State(s) (where you have a business address):
Business Address(es):
Phone number(s):
Email
Website:
Short Bio:
(if you put education or any other information - please include a header for each paragraph)
Types of Interventions you are Trained to Perform:
Substance Use Disorders
Mental Health
Process Addictions
Eating Disorders
When did you become a member of AIS?:
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