Licensed Mental Health Clinicians: Application to Provide Therapy
Please answer all questions to the best of your ability.
Date of Application
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Month
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Day
Year
Date
Personal Information
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
*
Please enter a valid phone number.
Professional Information
Professional Degree
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Date Received
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Month
-
Day
Year
Date
Institution received from or attending
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License Type
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License Number
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Date License Received
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Month
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Day
Year
Date
Languages Spoken
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Work with
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Children
Adolescents
Adults
Families
Couples
1-2 Specialty areas you would like listed (e.g. domestic violence, sexual assault, EMDR, TFT):
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Additional Certifications and credentials
How did you learn about Survivors of Torture, International (SURVIVORS)?
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Why are you interested in participating in the SURVIVORS’ Clinical Contract Network?
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Please explain your interest and experience in working with issues of recovery trauma.
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Please explain your interest and experience in working with issues related to human rights and social justice (including non-clinical activities).
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I am also interested in providing psychological forensic evaluations in addition to therapy:
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Yes
No
Email
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example@example.com
Phone Number
*
Please enter a valid phone number.
Reference #2
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Required Documents
Please attach the following required documents.
Your Professional CV/Resume
*
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A copy of your current license
*
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A copy of your malpractice insurance
*
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Survivors of Torture, International is an Equal Opportunity Employer
SURVIVORS prohibits discrimination against employees, applicants for employment, individuals providing services in the workplace pursuant to a contract, unpaid interns, or volunteers based on any legally-recognized basis, including, but not limited to, their actual or perceived race, color, religion, religious creed, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information, marital status, sex (including pregnancy, childbirth, breastfeeding, or related medical conditions), gender, gender identity, gender expression, age, sexual orientation, veteran and/or military status, protected medical leaves (requested or approved for leave under the Family and Medical Leave Act or the California Family Rights Act), political affiliation, domestic violence victim status, immigration status or any other status protected by state or federal law.”
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