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 Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City and State
*
Time Zone
*
Please Select
Eastern Time (ET)
Central Time (CT)
Mountain Time (MT)
Pacific Time (PT)
Alaska Time (AKT)
Hawaii-Aleutian Time (HAT)
Other
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)
*
Trauma
Anxiety
Depression
Substance Use
Couples/Family
Children/Adolescents
LGBTQIA+
Other
Populations Served (select all that apply)
*
Children
Adolescents
Adults
Older Adults
Families
Couples
Other
Languages Spoken (please list all)
*
Availability
Days of the Week Available (select all that apply)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Time Windows (please specify your available time ranges, e.g., 9am-12pm)
*
Preferred Session Length
*
Please Select
30 minutes
45 minutes
50 minutes
60 minutes
Other
Maximum Number of Clients You Can Take
*
Service Preferences
How can you provide services?
*
In-person
Virtual/Telehealth
Both
Preferred Platforms for Telehealth (if applicable)
Zoom
Doxy.me
Google Meet
Microsoft Teams
Other
Age Groups You Are Comfortable Working With (select all that apply)
*
Adults (18-64)
Older Adults (65+)
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?
*
Yes
No
Have you ever had a malpractice claim or disciplinary action against you?
*
No
Yes (please explain below)
If yes, please explain (otherwise leave blank)
Are you able to provide proof of licensure upon request?
*
Yes
No
Do you currently have professional liability insurance?
*
Yes
No
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?
Please Select
Colleague/Word of Mouth
Professional Organization
Social Media
Online Search
Other
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Application
Submit Application
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