ELC Volunteer Registration Form

Client Support Person (CPS)

Client Support Persons (CSPs): are inner wellness specialists who are licensed /experienced or credentialed as therapists, social workers, LCSW, mental health specialist, Christian counselors, or professionals of the Christian faith who are present at the center for as-needed client mental, spiritual, and emotional support interactions. CPSs are at the center during program hours of 3-6 pm and are available to clients on an as-needed basis.
Full Name*

First NameLast Name
Please select your current age range*

Over 18 under 21Over 21 under 35Over 35
E-mail*
example@example.com
Phone Number*
Can this number receive texts?*

YesNo
Availability*

Tuesday 3:00PM - 4:00PMTuesday 4:00PM - 5:00PMTuesday 5:00PM - 6:00PMWednesday 3:00PM - 4:00PMWednesday 4:00PM - 5:00PMWednesday 5:00PM - 6:00PMThursday 3:00PM - 4:00PMThursday 4:00PM - 5:00PMThursday 5:00PM - 6:00PM
Which CPS certification do you hold*

Social workerMental health worker / therapistChristian councilorProfessional of the Christian faith
Mental health specialist / social workers what credentials do you currently hold?
Where are you currently employed?
May we contact for a reference?

YesNo
If yes please give contact information: name, title and phone number of supervisor/manager or work reference
If no, please explain
If Christian counselor/professional, what organization and denomination are you currently affiliated with
Name of organization and denomination
What is your current title with that affiliation.
How many years have you served with this organization
Name of current Church or organization,
Name and title of that Church or organization's leader.
Pastor or leader's contact number.
Please enter a valid phone number.
May we contact for a reference?

YesNo
If yes please give contact information: name, title and phone number of supervisor/manager or work reference
If no, please explain
Please list a second reference from this church/ organization. This may not be a family member or relative
Second Reference Phone Number
Please enter a valid phone number.
Have you ever had any non motor vehicle arrest or convictions yes/ no*

YesNo
if yes list offense and year of conviction / arrest
Do you have any current or pending criminal charges. Are you currently on probation*

YesNo
if yes list offense and year of conviction / arrest
if on probation list name and contact number of probation officer
Have you ever been instructed not to have contact with children or do you have a history of sex offender registration?*

NoYes
To the best of my knowledge all of the provided information is true and accurate. *

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Client Support Person (CPS)