MHP Therapy Form

2. VOLUNTEER EXPECTATIONS & EXPERIENCE
2.1 How did you learn about Amudim?*
2.2 Why do you want to volunteer at Amudim? What do you expect from this experience?*
2.3 Please list any special areas of expertise or special skills (e.g. languages spoken, sign language, sexual abuse counseling, chemical dependency counseling, etc.).*

3 EMPLOYMENT EXPERIENCE
3.1 Have you ever been asked to resign or been terminated by a training program, volunteer position, or employer?*

YesNo
If Yes Please Explain:
NOTE: Amudim may be obligated to make written inquiry to past employers in the mental health field regarding possible sexual misconduct with clients.
3.2 List all current and past employment in the mental health field during the past five years OR state that you have not had any employment or paid internships in the mental health field in the past five years. Include part-time, temporary, and full time positions, and all paid internships. Please list chronologically beginning with the most recent. Provision for each such position: (1) The agency/organization, (2) start and end dates, (3) mailing address, (4) phone number, (5) title/position, and (6) description of role (setting, duties).*
(Please initial) blanks* I understand that my employer(s) may be contacted.

4. TRAINING & CREDENTIALS
4.1. Please list ALL degrees held (for each degree: identify the institute, degree, major field and year).*
4.2. Please list ALL current licenses and certifications in a mental health field (for each license/certification: identify the license, license number, state, start date and renew date).*
4.3. Please list any special areas of competency or professional practice for which you are trained, licensed, or certified.*
4.4 Has disciplinary action of any sort ever been taken against you by a licensing board, professional association, or an educational/training institution?*

YesNo
If yes, please explain
4.5 Are there any complaints pending against you before any of the above-named bodies?*

YesNo
If yes, please explain
4.6 Have you ever had a civil or criminal suit brought against you relative to your professional work or is any such action pending?*

YesNo
If yes, please explain

5. REFERENCES
Please provide contact information for three people who are familiar with or have supervised your client service work within the last five years. For each person, provide a (i) name, (ii) agency/organization, (iii) phone number, and (iv) email address.

REFERENCE 1
Name*

First NameLast Name
Agency/Organization*
Phone Number*

Country CodeArea CodePhone Number
Email*
example@example.com
REFERENCE 2
Name*

First NameLast Name
Agency/Organization*
Phone Number*

Country CodeArea CodePhone Number
Email*
example@example.com
REFERENCE 3
Name*

First NameLast Name
Agency/Organization*
Phone Number*

Country CodeArea CodePhone Number
Email*
example@example.com

6. STATEMENT OF APPLICANT
(Please initial) blanks*All information submitted by me in this application is true to the best of my knowledge. I understand that any significant misstatement in, or omission from, this application may be cause for denial of appointment or cause for dismissal from Amudim’s paid or volunteer staff. By applying for appointment to the paid or volunteer staff of Amudim, I acknowledge that I have the responsibility to read all Amudim rules and regulations, and I agree to act in accordance with those rules and any other rules or regulations adopted by Amudim. I also recognize I am bound and held to the ethical and professional standards associated with my professional degree and license in accordance with the state board responsible for my licensure. I authorize Amudim with its staff and representatives to consult with persons or institutions with which I have been associated and with others, including past and present employers, who may have information bearing on my professional competence, character, and ethical qualifications. I understand that a background check may be conducted as part of the selection process (and in the future from time to time) for this paid or volunteer position and I consent to that action. I release from liability all representatives of Amudim for acts performed in good faith in connection with evaluating my application and my credentials and qualifications. I also release from any liability all individuals and organizations who provide information to Amudim in good faith concerning my professional competence, ethics, character and other qualifications.
(Please initial) blanks* I understand and agree that I will notify Amudim Counseling Center of any changes in my job or training status, licensure, censure or sanction by professional bodies, or any other information relating to my ability to perform as a volunteer counselor.
(Please initial) blanks* I am not bound by any other agreement that prohibits or limits my engagement as a volunteer hereunder.
(Please initial) blanks I ACKNOWLEDGE AND AGREE THAT EXCEPT TO THE EXCEPT TO THE EXTENT EXPRESSLY AGREEMENT OTHERWISE IN WRITING BY AMUDIM, THIS IS A VOLUNTEER POSITION AND I WILL RECEIVE NO COMPENSATION FOR MY SERVICES TO AMUDIM AND ITS CLIENTS.
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Amudim Volunteer Counselor Application Form