Loving Serenity Counseling Services LLC

Loving Serenity Counseling Services

Contractor Application
Join our Team
Name
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Last 4 Numbers of SS
Languages fluently spoken in addition to English
Professional Information, Are you currently licensed as a Licensed Professional Counselor (LPC)?

YesNo
Emergency contact person

First NameLast Name
Emergency contact phone number
License Number
Issuing State:

MonthDayYear
Date
License Expiration Date:

MonthDayYear
Date
Are you fully insured for professional liability/malpractice coverage?

YesNo
Scope of Care
Type of Provider
Specialty or Care Area
What type of Service can you provide

Family CounselingGroup CounselingInduvalual TherapyGroup TherapyTelehealthRecovery CoachCommunity Support ProgramRecovery Support NavigatorSupervisionAll of the Above
Are you currently credentialed with any insurance panels?

YesNo
Resume or CV
Degree Earned:
Graduation Date:

MonthDayYear
Date
Additional Certifications or Specialized Training:
Populations Served (Check all that apply):

☐ Children☐ Adolescents☐ Adults☐ Couples☐ Families
Therapeutic Modalities Used:

☐ CBT☐ DBT☐ Trauma-Informed☐ Faith-Based☐ Other: _______________
Experience: Years of Clinical Experience:
Please indicate highest number of hours you are able to work in a day
Work Status
Graduate School Name
Degree Earned:
References Please provide two professional references: Name: Relationship: Phone/Email:
☐ Resume or CV

Cancelof
☐ Headshot Picture

Cancelof
☐ Copy of LPC License

Cancelof
Signature

Powered by Jotform SignClear
Should be Empty:

Loving Serenity Counseling Services

Join our Team

Scope of Care