Volunteer Application for Mental Health Professionals

Volunteer Application for Mental Health Professionals

Apply to join our volunteer counseling program as a licensed counselor, therapist, or qualified mental health professional.
Contact Information
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
City and State
Time Zone
Professional Details
License Type (e.g., LCSW, LPC, LMFT, Psychologist, etc.)
License Number
State of Licensure
Years of Experience
Primary Specialties (select all that apply)

Other
Populations Served (select all that apply)

Other
Languages Spoken (please list all)
Availability
Days of the Week Available (select all that apply)
Time Windows (please specify your available time ranges, e.g., 9am-12pm)
Preferred Session Length
Maximum Number of Clients You Can Take
Service Preferences
How can you provide services?
Preferred Platforms for Telehealth (if applicable)

Other
Age Groups You Are Comfortable Working With (select all that apply)
Are there any issues or populations you do NOT want to work with? (please specify)
Screening & Safety
Are you currently in good standing with your professional licensing board?
Have you ever had a malpractice claim or disciplinary action against you?
If yes, please explain (otherwise leave blank)
Are you able to provide proof of licensure upon request?
Do you currently have professional liability insurance?
Program Fit
Why do you want to volunteer with this program?
Please describe any relevant experience with trauma, crisis, or community mental health.
Do you have any supervision needs or preferences?
Logistics & Consent
How did you hear about this program?
Signature
Date

MonthDayYear
Date
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Volunteer Application for Mental Health Professionals

Contact Information

Professional Details

Availability

Service Preferences

Screening & Safety

Program Fit

Logistics & Consent