To help us address your specific needs related to starting and building a Private Practice, copy and paste your responses to this questionnaire into an email (either as an attachment or in the body of the email) and send to Dr. Sally Gelardin, sal@jobjuggler.net .

1. PREFERRED METHOD OF CONTACT:

1.a. Name
1.b. Institution/Agency
1.c. Phone
1.d. Fax
1.e. Email

2. ALTERNATIVE METHOD OF CONTACT
2.a. Name
2.b. Institution/Agency
2.c. Phone
2.d. Fax
2.e. Email

3. EDUCATlON & TRAINING (include year earned):
3.a. List university degrees.
3.b. If you have earned other education (i.e., vocational, college) and certificates, list here.

4. WORK EXPERIENCE
Have you worked in a career development or in related employment? If yes, please describe.

5. MEMBERSHIPS
Have you been involved in any career-related organizations? If yes, describe here.

6. ASPIRATIONS
What are your reasons for wanting to learn more about starting and growing a private practice?