bWc Interest Form
Full Name
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Pronouns
Email address
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Phone number
Licensure/or current professional statuse.g., PHD, PSYD, LMFT, AMFT, LCSW, LPCC, Psych Associate, Pre-licensed clinician, student intern, etc.
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Years of clinical experience Open to all levels - this is just for context.
In what type of setting are you currently practicing? Private practice, agency, school-based, community mental health, etc.
Current location/timezone? Helpful for context & scheduling
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Experience, Goals & Intentions
What clinical themes, populations, or questions are you currently sitting with most often? Please provide a brief statement of your clinical philosophy and approach to client care.
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Specialty areas that feel most aligned to your wants/needs (check all that apply)
Case conceptualizations ('supervision' style, client-centered discussions, alternative perspectives, resourcing, case formulations)
Understanding trauma as more than a set of symptoms, but as a social responsibility, a systemic issue, and neurobiological 'disease' prevention, etc.
Enhance traditional therapeutic models (complex trauma, neurobiological frameworks, harms reduction, somatic, anti oppressive, liberation oriented, etc.)
Demystifying 'taboo' topics in therapy space (sex, kink, infidelity, crime, money, politics, body size, gender, polyamory, race, religion, etc.)
Staying connected & in community with other therapists (combatting isolation, hyper-individualism, scope, ethical issues, clinical policies)
Retention, Rapport, Marketing, & Referrals (networking, relational presence, niche development, pricing, insurance, etc.)
Blending Mentorship/Management/Leadership with Therapeutic Roles
Work-Life Balance & Burnout Prevention (boundaries, self-care, sustainable scheduling)
Other...
This space centers reflection, humility, curiosity and shared responsibility. Are you open to receiving gentle feedback or being invited into deeper exploration of your language, assumptions, or impact?(If so, how do you tend to respond in this moments - and how can I best support you if they were to arise?)
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What are you hoping to gain, explore, learn, or unlearn in a space like this?
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This space is intended to honor identity, context, and lived experience. (Optional but encouraged) - Is there anything you’d like me to know about your identity, culture, clinical background, or needs that you would like me to know?
Which days and times are you generally available to meet for consultation?While this helps with scheduling, but is flexible, more of what you are hoping for, & subject to change
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Morning (9am-12pm)
Afternoon (1pm-5pm)
Evening (6pm-9pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Would you like to be added to my email list to hear about future groups or offerings?
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Yes please!
No thank you
Already on it
Is there anything else you would like us to know regarding your fit for this role?
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