Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Education and Experience

Highest Degree Earned:

Master's

Doctorate's

Areas of Specialization (check all that apply):

Individual Therapy

Couples/Relationship Therapy

Family Therapy

Trauma Therapy

Grief Counseling

Perinatal Mental Health

Anxiety & Depression

Stress Management

Licensing Information

Licensure Type:

Licensed Professional Counselor (LPC)

Licensed Mental Health Counselor (LMHC)

Licensed Marriage and Family Therapist (LMFT)

Licensed Clinical Social Worker (LCSW)

Licensed Clinical Professional Counselor (LCPC)

Certified Clinical Mental Health Counselor (CCMHC)

Availability (check all that apply): *

Week Days

Weekends

Fixable

Preferred Client Types (check all that apply): *

Children/Teens

Adults

Couples

Families

All listed above

Work Preferences *

Preferred Therapy Setting:

In-Person

Virtual

Both

Professional Liability Insurance *

Do you have current professional liability insurance?

Yes

No

Submit *

By submitting this application, I certify that all information provided is accurate and complete to the best of my knowledge. I understand that providing false information may result in disqualification from the application process or termination of a contract with OWR Therapy.

I have Read and understand all these terms.

I agree to these terms