Counselor Page Change Request Form

This form is to request changes to your individual counselor bio page for the website. Please watch the video below to understand how the Counselor Pages function, and how the filters are tied into your page!

"*" indicates required fields

Photo Update (email new photo to cantor@chesterfieldca.com)
Do you have a Title update? (displayed under your name, connected to search filter)
Currently contact button options are: (1) Email (2) Simple Practice Contact Form (3) Simple Practice Appt or Consult Scheduling
I work with (select ALL from Predefined List that apply to you, connected to filter)
Areas of Specialty (select ALL from Predefined List that apply to you, connected to filter)
Clinical Focus Areas (select ALL from Predefined List that apply to you, connected to filter)
Examples: Gottman Level I & II, EMDR Certified through [EMDRia, etc.], SYMBIS Certified, etc. Please list out the Name of the Certification, and the WEBSITE LINK of the place you got the certification from because I am pulling the logo. If they gave you a certification image logo, please email that to CAntor@chesterfieldca.com