FAON Application

Family Advocacy Outreach Network (FAON) Membership Application
Thank you for you consideration in joining The Family Advocacy Outreach Network (FAON), a program run by the National Center for Missing & Exploited Children (NCMEC)!

FAON members are referred NCMEC cases in need of counseling services with low-cost options, such as pro-bono, sliding scale, and in-network insurance. These cases involve children, adults, and families that have experienced crimes such as abduction, a voluntary missing incident, online sexual exploitation, sextortion, molestation, sex trafficking, and more.

We look forward to learning more about your experiences as a mental health provider, and the support you can offer to referred NCMEC cases. To begin your membership process, please complete the application below.

For more information please visit our website https://www.missingkids.org/support#faon
Please contact FAON@NCMEC.org if you encounter problems or have any questions.

There is an option to save and continue your progress later at the end of this form.
Applicant Information
Applicant Name

First NameLast Name
Organization Name
Website
Job Title
Applicant Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Applicant Email Address
example@example.com
Professional License
I am interested in joining FAON as a...
Professional's Name:   First Name*   Last Name*
License Number:   *
Type of License (LMFT, LCSW, LPC, etc.):   *
Licensing State:   *
License Expiration Date:   Type a label*
Please provide your license information. If you are un-licensed, please list the license information of a provider(s) in your organization (such as a clinical director).

Professional's Name:   First Name*   Last Name*
License Number:   *
Type of License (LMFT, LCSW, LPC, etc.):   *
Licensing State:   *
License Expiration Date:   Type a label*
Please provide the following information about your supervisor.

Professional's Name:   First Name*   Last Name*
License Number:   *
Type of License (LMFT, LCSW, LPC, etc.):   *
Licensing State:   *
License Expiration Date:   Type a label*
Do you want to add an additional license (Up to 3)?
Professional's Name:   First Name   Last Name
License Number:
Type of License (LMFT, LCSW, LPC, etc.):
Licensing State:
License Expiration Date:   Type a label
Professional's Name:   First Name   Last Name
License Number:
Type of License (LMFT, LCSW, LPC, etc.):
Licensing State:
License Expiration Date:   Type a label
Professional's Name:   First Name   Last Name
License Number:
Type of License (LMFT, LCSW, LPC, etc.):
Licensing State:
License Expiration Date:   Type a label
If you have more licenses to list, please provide that information here:
Other Organization Staff Members

If applicable, please enter the names and contact information for any staff members that can provide clinical services to NCMEC cases. This will help us have a better understanding of services provided and who to contact directly for specific needs. You may add up to 10 additional staff members.
Staff Member's Name:   First Name   Last Name
Title/Role:
E-mail:   Email
Direct Number:   Area Code   Phone Number
Staff Member's Name:   First Name   Last Name
Title/Role:
E-mail:   Email
Direct Number:   Area Code   Phone Number
Staff Member's Name:   First Name   Last Name
Title/Role:
E-mail:   Email
Direct Number:   Area Code   Phone Number
Staff Member's Name:   First Name   Last Name
Title/Role:
E-mail:   Email
Direct Number:   Area Code   Phone Number
Staff Member's Name:   First Name   Last Name
Title/Role:
E-mail:   Email
Direct Number:   Area Code   Phone Number
Staff Member's Name:   First Name   Last Name
Title/Role:
E-mail:   Email
Direct Number:   Area Code   Phone Number
Staff Member's Name:   First Name   Last Name
Title/Role:
E-mail:   Email
Direct Number:   Area Code   Phone Number
Staff Member's Name:   First Name   Last Name
Title/Role:
E-mail:   Email
Direct Number:   Area Code   Phone Number
Staff Member's Name:   First Name   Last Name
Title/Role:
E-mail:   Email
Direct Number:   Area Code   Phone Number
Staff Member's Name:   First Name   Last Name
Title/Role:
E-mail:   Email
Direct Number:   Area Code   Phone Number
Has there ever been disciplinary action against you, the agency or any of the professionals in the group (including, but not limited to, reprimand, suspension or revocation of license)?
Please provide detailed information for each incident:
Service Details
Have you supported any clients impacted by the missing and exploited child case types listed below?

Other
If you offer services in any languages other than English, please list them:
How do you provide services?

Other
What is the address of your in-person location?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you want to add another in-person location (Up to 3)?
What is the address of your in-person location?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the address of your in-person location?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the address of your in-person location?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you have more in-person locations to list, please provide that information here:
What US states/territories do you provide virtual services in?
What is your mailing address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Treatment Modalities:

Other
What ages do you work with?
What is your self-pay rate for individual counseling?
What is your sliding scale/reduced fee rate and how is it determined?
FAON membership requires clinicians and agencies to provide a low-cost rate to NCMEC referred clients who don't have insurance.
Do you offer pro-bono services and what are the requirements?
Which insurances are you in-network with?
Please list any additional payment methods you accept:
Do you have professional liability insurance?
Which days and times do you provide counseling services?
Do you currently, or often, have a waitlist for counseling services?
What is your current or typical waitlist?
Is there anything else that you would like us to know about yourself or your practice/organization that this application did not address?
This may be certain populations, cultural competencies, or other specializations or services you offer, that you would like us to know about.
How did you hear about FAON?

Other
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Family Advocacy Outreach Network (FAON) Membership Application

Applicant Information

Professional License

Other Organization Staff Members

Service Details