Application Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Are you currently licensed to provide counseling services in Texas?
*
Yes
No
Are you currently able to provide counseling services independently without supervision?
*
Yes
No
Have you been convicted of or pleaded guilty to a felony within the last five years?
*
Yes
No
If yes, please explain:
Have you had you received a board complaint or had your licensed suspended?
*
Yes
No
If yes, please explain:
Are you eligible to work in the United States?
*
Yes
No
Are you currently residing full time in Texas?
*
Yes
No
Do you have a National Provider Identification Number (NPI)?
*
Yes
No
What type of license do you have?
*
Highest Degree Obtained?
*
Describe previous relevant experience in providing counselling services.
*
Describe your experience with teletherapy.
*
Are you able to devote at least 15 hours per week to working with VCounselors?
*
Yes
No
How would you describe your treatment approach and how does it help your clients:
*
Today's Date
*
-
Month
-
Day
Year
Date
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
*
APPLY NOW >
Should be Empty: