Therapist Referral Form
We are seeking to list therapist who are willing to provide pro bono or low cost counseling to actors who require specialized support addressing the unique mental, emotional, and professional pressures of the entertainment industry, such as chronic rejection, intense role immersion, addressing burnout, anxiety, and identity issues. Most of the actors who reach this website will be newly graduate from a BFA or MFA Acting Program who can not obtain insurance due to the lack of work credits within an Union.
Full Name
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First Name
Last Name
Company Name (if applicable)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
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example@example.com
Website
Phone Number
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Format: (000) 000-0000.
Mental Health Role
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Please Select
I am licensed, my license information is below
I am pre-licensed or under supervision
License Number
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Additional License Info
*
License State
License Expiration Date (mon/year)
Have you counsel with Actors?
*
Please Select
YES
NO
Are you willing to provide a limited amount of pro bono work to support Actors?
*
Please Select
YES
NO
Are you willing to accept low cost ($10-$60) sessions to support Actors?
*
Please Select
YES
NO
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