North Georgia GMC Christian Counseling Database

North Georgia GMC Christian Counseling Database Application
Thank you for your interest in joining our database. Please complete all questions to be considered. Filling out the application does not guarantee inclusion on our list. The information you provide is for our use only and will not be shared with any other parties.

Once submitted, someone from our team will contact you to schedule a brief phone interview. You may ask any of your own questions at this time as well. If approved for inclusion, the website will be updated on a quarterly basis. Any updates to your information will need to be provided by you to our team as we are not responsible for ensuring the accuracy of your information.

Any referrals of potential clients are expected to be handled in appropriate professional and Christ-like manners. We require all counselors on this list to have active licensure in their profession and carry liability insurance.

Thank you. Questions can be directed to Rev. John Moore.
PERSONAL INFORMATION
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Degree in Related Field of Counseling
University Attended and Graduation Year
State(s) in which you currently hold a counseling license
Licensure Number
Any affiliated memberships (AACC, APC, etc.)
Current Employment Status (full time, part time, self-employed, etc.)
Professional Agency Name
Professional Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Professional Agency Website
Professional Agency Phone (if different from above)
Please enter a valid phone number.Format: (000) 000-0000.
Do you meet in person, via telehealth, or both options?
PROFESSIONAL INFORMATION
Please give a brief description of your professional history working in the counseling field and desired populations you serve.
Do you have any other certifications or specialties not already listed above? (EMDR, TF-CBT, etc.)
Do you offer services in languages other than English? If yes, what language(s)?
Do you carry liability or malpractice insurance and are willing to share a certificate of insurance?
Have you ever had a malpractice claim? If yes, what was the result?
What is your average session rate?
Do you have sliding scale/reduced fees available for self-pay?
Do you accept insurance?
Addiction (Alcohol, Drugs, Process, etc.)ADHDAdoption CounselingAnger ManagementAnxietyAutismBipolar and Related DisordersCareer CounselingDialectical Behavioral Therapy (DBT)DepressionDissociative Identity Disorder (DID)Domestic ViolenceEating DisordersEye Movement Desensitization Reprocessing (EMDR)Grief CounselingLGBTQ+ / Gender DysphoriaMarriage Counseling / PremaritalObsessive-Compulsive Disorder (OCD)Parenting / Family CounselingPlay TherapyPersonality DisordersSchizophrenia / Other PsychosesSleep / InsomniaTesting / EvaluationsTrauma / PTSDOther
ChildrenTeensAdults
COUNSELING THEORY INFORMATION
What is your primary theoretical orientation for counseling? Please explain how you use this theory to assess and treat problematic behaviors.
How do you integrate scripture or spirituality within your practice?
If spirituality is used as a component, how do you handle a client that has a different religious belief or spiritual orientation than you?
How do you see church fitting into the counseling process or a client’s support system?
Do you believe political “hot topics” should be discussed in a counseling session? If so, why?
Do you have any regular accountability or consultation as a professional counselor?
How do you determine whether a client is making progress or ready for termination from therapy?
SPIRITUAL INFORMATION
What is your definition of a Christian?
YesNo
How would you describe your relationship with Jesus Christ?
How do you describe the meaning and purpose of the Bible for modern cultures such as this?
What is your view of God in the healing process of someone’s life?
What is your view of prayer in the healing process?
What Christian leader has great influence on your beliefs?
Do you attend or are you involved in a church? If yes, what church and denominational affiliation?
REFERENCES

Please provide two references who are familiar with your counseling work as well as your pastor’s contact information. Please inform your references they will be contacted.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pastor's Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please inform your references they will be contacted.
Should be Empty:

North Georgia GMC Christian Counseling Database Application

PERSONAL INFORMATION

PROFESSIONAL INFORMATION

COUNSELING THEORY INFORMATION

SPIRITUAL INFORMATION

REFERENCES