Full Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Current Educational Status: *

Highest Degree Earned:

Graduate Student

Postgraduate

What areas of mental health are you most interested in? (check all that apply): *

Individual Therapy

Couples/Relationship Therapy

Family Therapy

Trauma Therapy

Grief Counseling

Perinatal Mental Health

Anxiety & Depression

Stress Management

Experience *

Have you completed any internships or volunteer work in mental health?

Yes

No

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

Supervision Preferences *

Do you require supervision hours for licensure or graduation requirements?

Yes

No

Preferred Type of Supervision: *

Individual

Group

Both

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.

I have Read and understand all these terms.

I Agree to the terms and conditions.