TheraRise Associate Clinician Application
Before beginning the application, please have the following information prepared: (1) resume/cv, (2) unofficial graduate transcript, (3) proof of APC status if applicable, (4) 2 professional references.
Personal Information
Name
*
First Name
Last Name
Preferred Name (if different)
Pronouns
*
She/Her
He/Him
They/Them
Other
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Licensure & Professional Status
Current Professional Status
*
Currently licensed as an Associate Professional Counselor (APC)
Graduated and eligible to apply for APC licensure
Current graduate student (anticipated graduation within the next 6 months)
If currently licensed as an APC:
APC License Number:
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Date Issued:
Expiration Date:
If not yet licensed:
Are you ready to submit your application with all requirements met?
Yes
No
Other
Education
University
*
Degree Earned
*
Graduation Date
*
Back
Next
Clinical Experience
Graduate Practicum Site(s)
Agency/Organization
*
Supervisor Name & Title
*
Start Date
*
/
Month
/
Day
Year
Date
End Date
*
/
Month
/
Day
Year
Date
Populations Served
Agency/Organization
Supervisor Name & Title
Start Date
/
Month
/
Day
Year
Date
End Date
/
Month
/
Day
Year
Date
Populations Served
Graduate Internship Site(s)
Agency/Organization
Supervisor Name & Title
Start Date
/
Month
/
Day
Year
Date
End Date
/
Month
/
Day
Year
Date
Populations Served
Agency/Organization
Supervisor Name & Title
Start Date
/
Month
/
Day
Year
Date
End Date
/
Month
/
Day
Year
Date
Populations Served
Back
Next
Clinical Interests
Which populations are you most interested in working with?
Anxiety
Depression
Trauma
Couples
Adults
Adolescents/Teens
Children
Families
LGBTQIA+
Infertility & Family Building
Pregnancy & Postpartum
Parenting
Grief & Loss
Relationships
Life Transitions
Other
Theoretical Orientation Interests
CBT
ACT
DBT
Person-Centered
Attachment-Based
Psychodynamic
Narrative Therapy
Internal Family Systems (IFS)
Emotionally Focused Therapy (EFT)
Solution Focused
Other
Professional Goals
What interests you about the TheraRise Associate Clinician Program?
What are your long-term professional goals?
Back
Next
Experiences & Skills
Clinical Skills
Rows
None
Limited
Comfortable
Extensive
Conducting Intake Assessments
Developing Treatment Plans
Writing Progress Notes
Risk Assessment
Safety Planning
Telehealth Services
Working with High-Risk Clients
Collaboration with Other Professionals
Clinical Organization & Documentation
Marketing & Networking
Which Electronic Health Record (EHR) systems have you used?
No prior EHR experience
TherapyNotes
Simple Practice
Sessions Health
Valant
Epic
Other
Which telehealth platforms have you used?
Back
Next
Professional References
Please provide the information for two professional references who can speak to your professional character, clinical training, work ethic, or readiness for clinical practice. References may include practicum or internship supervisors, professors, or other professional colleagues.
Reference #1
Name
Credentials/Title
Organization/Affiliation
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to You
Length of Time You've Been Associated
Reference #2
Name
Credentials/Title
Organization/Affiliation
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to You
Length of Time You've Been Associated
File Upload
Please upload your resume, unofficial graduate transcript, and verification of APC licensure status (if applicable).
Resume/Curriculum Vitae (CV)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Unofficial Graduate Transcript
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Copy of APC Licensure or documentation of current licensure status (if applicable)
Browse Files
Drag and drop files here
Choose a file
a screenshot of the SOS website or GOALS application status is fine
Cancel
of
Submit
Should be Empty: