CoVid Mental Health Responders
Confidential Contact Information
for office use only
Name
*
First Name
Last Name
Email
*
example@example.com
Join our Mailing List
Add my email to the Crossings Mailing List
Phone Number
*
-
Area Code
Phone Number
How would you like Clients to Contact You?
What state are you licensed in?
*
Maryland
Virginia
District of Columbia
Licensed As (Scope of Practice Require licensure in one of these professions):
*
Psychologist
LCSW
Marriage and Family Therapist
LCPC
Pastoral Counselor
Psychiatrist
Nurse Psychotherapist
What is your Trauma Training Background
SE
EMDR
Sensori-motor
Other
The Term of this Program will end July 1, 2020
*
I understand that Crossings is acting solely as a facilitator of connection between providers and potential clients. Any clients taken through this volunteer program are my clients, and I accept professional responsibility and liability for their care
I understand that I can withdraw at any time
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