Please complete the following questions honestly.  Based on your answers to these questions, you will either be sent to complete the Provider application OR prevented from continuing if your answers are not appropriate.  Understand that falsely answering any of the following questions can have serious consequences.

NOTE: The first page of the provider application, directly following this screener, may ask for additional information, when appropriate, for some of the questions listed below.

Thanks again for your cooperation and participation.
 

1) Do you have a current license in good standing, by the State of Louisiana as a physician, psychologist, psychiatrist, professional counselor, or clinical social worker?
(NOTE: A Louisiana license is NOT Required to be an Associate Professional)
2) Have you ever had any complaints validated against you by a licensing board for sexual or violent misconduct or behavior?
3) Have you ever been convicted of a felony without pardon? 
4) Have you ever had a validation, adjudication, or conviction for an offense of any kind involving sexual or violent misconduct or behavior?
5) Do you commit to follow the ethical standards and principles established by the Association for the Treatment of Sexual Abusers (ATSA)?
6) Do you commit that if you provide risk assessments and sexual offender treatment, that you will provide Risk Assessment and sexual offender treatment as outlined in the definitions provided by the Interagency Council utilizing only techniques and methods currently promoted and accepted in the field of sexual offender treatment?
7a) Are you a member of the Association for the Treatment of Sexual Abusers (ATSA)?  (It is NOT required to be a member of ATSA to be on the registry)**
7b)

Are you a member of the Louisiana Chapter of the Association for the Treatment of Sexual Abusers (LA ATSA)?**
* * Answering NO to these questions will not prevent you from completing the online provider application or from being listed in the Treatment Provider Registry Provided questions 1-6 were answered correctly.