General Information
Name
*
First Name
Last Name
Birth Date
*
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Year
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you authorized to work in the United States
*
Yes
No
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Required Documents
Please upload a copy of your current professional license (LPC, LMFT, LCSW, PsyD, etc)
*
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Please upload your malpractice/liability insurance certificate
*
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Please upload a copy of your graduate degree/diploma
*
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Please upload any additional certifications or specialties (e.g., EMDR, Gottman, DBT, etc)
*
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Please upload your resume or CV
*
Browse Files
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Clinical Focus and Niche
What populations do you specialize in working with? (Check all that apply)
*
Children
Teens
Adults
Couples
Families
Group Therapy
What clinical issues do you enjoy working with? (Check all that apply)
*
Anxiety
Depression
Trauma
Relationship Issues
Addiction
Grief/Loss
Faith/Christian Counseling
Other
If other please specify
What is your preferred client gender
*
Male
Female
No preference
What therapeutic modalities do you use or are trained in? (e.g., CBT, IFS, EMDR, Gottman, DBT, Play Therapy, etc.)
*
What is your theoretical orientation or approach to therapy?
*
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Availability
What is your general availability? (Days/Hours per week, weekends, evenings, etc.)
*
What would be a comfortable starting date for you
*
-
Month
-
Day
Year
Date
Are you willing to see clients:
*
In person
Virtual
Hybrid
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Experience & Practice Fit
How many years of post-licensure experience do you have
*
Have you worked as a 1099 contractor before
*
Yes
No
Do you have experience using EHR systems? If yes, which one(s)
*
What is your ideal caseload per week
*
How many clients are you able to see comfortably per week
*
1-5
5-10
10-15
15-20
How do you handle no-shows or cancellations
*
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Personal Values & Practice Culture Fit
How comfortable are you with marketing yourself to the community
*
Not comfortable at all
0
1
2
3
4
Very comfortable
5
0 is Not comfortable at all, 5 is Very comfortable
How would you describe your cultural competence and approach to working with diverse populations
*
Are you comfortable working in a faith-informed environment that welcomes clients from all backgrounds
*
What are your long-term professional goals
*
What makes you a good fit for our practice
*
Are there any specific client issues or populations that you do not work with? Please explain
*
Collin Care Counseling is a faith-informed practice grounded in Christian values. While identifying as Christian is not a requirement, we seek team members who are respectful of our faith-based approach. How do your personal values or worldview align with working in this type of setting?
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References
Please list two (2) references that are familiar with your work life.
Reference
*
Reference
*
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