As a practitioner do you meet ALL of the criteria (a-f) listed on the previous page?  Yes No

   Practitioner Name

   Additional Practitioner Name (if any)

   Name of Practice (if any)

   Address Line 1

   Address Line 2

   City

   State (All Caps abbreviation)           Zip

   Country

   Phone        Fax

  Email Address

  Website

Practitioner Type 
(Example - MD, Neurologist, Naturopath, Chiropractor, Nutritionist, etc.)

Treatments
What type of treatments do you use? 

Do you accept Insurance?  Yes No

Do you accept Medicare/Medicaid? Yes No

Psychiatric Drugs?
Do you prescribe any psychiatric drugs?   
If you do prescribe psychiatric drugs, under what circumstances and for how long?

Help Off Psychiatric Drugs?
Do you help take patients off of psychiatric drugs if they wish to do so?   
Any comments about taking patients off of psychiatric drugs, such as under what conditions, procedure etc.

Other Notes: 
Any other relevant information you wish to provide to the public.

Testimonials?
Do you have any testimonials you would like to submit?  Yes No

Testimonials URL
If testimonials to use are already online, what is the URL?  
(If not online, please submit by email to safeharborproj@aol.com ) or fax to 
626-791-7869 or mail them to 787 W. Woodbury Rd., #2, Altadena, CA 91001

Client Types
What type of clients do you serve?