1. Your Name:

2. Practice Name:

3. Street Address:

4. Mailing Address:

5. City:

6. State:

7. Zip Code:

8. Telephone:

(             )

9. Fax Number:

(             )

10. E-mail Address:

11. Web Site:

12. Please list your current licenses & certifications:

13. How many years have you been a licensed professional?

14. How familiar are you with the treatment of Obsessive Compulsive Disorder (OCD)? (Please select only one answer.)

¨ No training/experience

¨ Little training/experience

¨ Significant training/experience

¨ It is a specialty area

15. How familiar are you with the spectrum disorder of Trichotillomania?   (Please select only one answer.)

¨ No training/experience

¨ Little training/experience

¨ Significant training/experience

¨ It is a specialty area

16. How familiar are you with the spectrum disorder of Body Dysmorphic Disorder?   (Please select only one answer.)

¨ No training/experience

¨ Little training/experience

¨ Significant training/experience

¨ It is a specialty area

17. Are you now or have you ever been a member of the National Obsessive-Compulsive Foundation?

¨ Never a member

¨ Active member at the current time

¨ Past member (How Long ago? ______________)

18. Please estimate the percentage of your current practice that is devoted to:

Children (4 – 11 yrs.)?

Adolescents (12 – 18 yrs.)?

Adults (19 yrs. +)?

18. What percentage of your current practice is devoted to treating individuals with OCD or associated spectrum disorders?

Children (4 – 11 yrs.)?

Adolescents (12 – 18 yrs.)?

Adults (19 yrs. +)?

19. If you are treating individuals with OCD, please describe your theoretical orientation

20. What percentage of those patients being seen for OCD or associated spectrum disorders is also being treated for problems such as depression, marital discord, or family issues?

Children (4 – 11 yrs.)?

Adolescents (12 – 18 yrs.)?

Adults (19 yrs. +)?

21. Please estimate how many individuals you’ve treated for OCD or associated spectrum disorders:

22. Please list any specialized training that you have received in the cognitive-behavioral treatment of anxiety disorders.

When?

Where?

How Many Hours?

23. How familiar are you with the intervention of exposure and response/ritual prevention or ERP? (Mark only one answer)

¨ No training/experience

¨ Little training/experience

¨ Significant training/experience

¨ It is a specialty area

24. Are you currently using ERP in the treatment of your OCD patients?

¨ Never use it

¨ Sometimes use it

¨ Frequently use it

¨ Always use it

25. Is there a psychiatrist familiar with OCD psychopharmacology in your practice, or one available to the OCD patient in your community?

¨ Yes

¨ No

¨ Uncertain

26. Do you offer a support group for OCD patients and/or their families

¨ Yes

¨ No

¨ I refer them to a support group in the community

27. Please list the standardized instruments that you use to measure your OCD patients symptoms:

28. If you do not treat OCD in your practice or are unfamiliar with ERP, do you use a referral source?     ___ Yes     ___ No

29. If “yes” would you supply us with their name, address, license type, and phone number?  We would also like to contact them regarding their work with OCD patients.

31. Do you have any other comments or notes that you would like to share with us at this time?