Provider Interest Form

Provider Interest Form
Provider Information:
Full Name*

First NameLast Name
Preferred Pronoun
City of Residence
State*
Phone Number*
E-mail*
example@example.com
Are you currently licensed to practice?*

YesNo
Licensure Type*
If Other, please explain.
What states are you currently licensed?*
Years of Clinical Experience*
Do you currently carry professional liability insurance?*

YesNo
Do you have experience working with any of the following populations?

Formerly Incarcerated IndividualsTrauma SurvivorsBIPOC ClientsLGBTQIA+ ClientsRe-entry PopulationsOther
If Other, please explain.
Have you worked in any of the following settings?

Correctional InstitutionsRe-entry ProgramsCommunity Mental HealthPrivate PracticeOther
If Other, please explain.
Are you available for virtual sessions?*

YesNo
How many clients are you currently able to take on through this program?*
Why are you interested in joining Life After Justice’s Mental Health & Wellness Empowerment Program?
Is there anything else you'd like us to know about your background, interest, or availability?
I understand that completing this form does not guarantee onboarding but serves as an expression of interest.*

Yes
How did you hear about this opportunity?*

LAJ WebsiteSocial MediaReferral / Peer
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