Chief of Clinical Care Email Title Choose One Mr. Ms. Mrs. Prof. Dr. First Name * Last Name * Email Address * Phone Number * Please check the states in which you are licensed to practice * Maryland Washington DC Virginia How many hours a week are you willing to provide care? * When are you available to provide care? (Please select all that apply) * Monday Mornings (8-12) Monday Afternoons (12-4) Monday Evenings (4-9) Tuesday Mornings (8-12) Tuesday Afternoons (12-4) Tuesday Evenings (4-9) Wednesday Mornings (8-12) Wednesday Afternoons (12-4) Wednesday Evenings (4-9) Thursday Mornings (8-12) Thursday Afternoons (12-4) Thursday Evenings (4-9) Friday Mornings (8-12) Friday Afternoons (12-4) Friday Evenings (4-9) Saturday Mornings (8-12) Saturday Afternoons (12-4) Saturday Evenings (4-9) Sunday Mornings (8-12) Sunday Afternoons (12-4) Sunday Evenings (4-9) How many years of Mental Health Counseling do you have? * What is the highest level of education you have completed? * Do you have the following license or certification: LCSW or equivalent? * Are you willing to undergo a background check, in accordance with local law/regulations? * Yes No Have you had training/education to use trauma and CBT Techniques within your practice of counseling (i.e., certification, formal training, or postgraduate training) . If so, describe the nature of your training and experience within your practice. * Have you had any infractions or formal complaints against your license? If so, please explain. * Are you credentialed with any major insurance payers? If so, please provide a list of which one(s). * Please provide us with two references (one professional and one personal) Professional reference: Name * Phone Number * Email Address * Personal reference: Name * Phone Number * Email Address *