Chief of Clinical Care Application

Title

First Name

Last Name

Email Address

Phone Number

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?

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