Therapist/Provider Application

1. Personal Information

Name

First

Last

Phone

professional Other (if

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

2. Professional Information

Degree, License(s), and Certification(s): Please specify type, state, and license number

Highest Degree Earned

License Type

License #

State License Issued

Additional Certifications (if any):

Years of Experience in Mental Health Counseling:

Specialties / Areas of Expertise:

(e.g., anxiety, depression, trauma, family counseling, addiction)

Languages Spoken:

3. Availability

Preferred Work Hours:

Mornings
Afternoons
Evenings
Weekends

(Check all that apply)

Preferred Client Populations:

(Check all that apply)

Other (Please Specify)

4. Clinical Approach & Philosophy

Briefly describe your clinical approach and therapy philosophy:

5. Technology and Telehealth Experience

Do you have experience in providing telehealth services?

Yes
No

Familiarity with Telehealth Platforms:

(e.g., Zoom, Doxy.me, TherapyNotes)

Do you have access to a private, professional space to conduct telehealth sessions?

Yes
No

6. Additional Questions

Please name your professional liability insurance carrier

Professional liability insurance carrier (upload copy):

Click or drag a file to this area to upload.

Why are you interested in joining CounselingWorld.com?

Have you ever been involved in any professional disciplinary and/or liability actions?

Yes
No

If yes, please provide details:

7. References

(List two professional references)c

Name

First

Last

Name

First

Last

Relationship

Phone

Email

Authorization

Authroization

By submitting this application, I affirm that all information provided is accurate and complete. I authorize CounselingWorld.com to verify my credentials and contact references as part of the application process.

Name

Date

Thank you for your interest in joining the CounselingWorld.com team!

Please complete the information below to apply as a provider for our online tele-health counseling programs.

1. Personal Information

2. Professional Information

3. Availability

4. Clinical Approach & Philosophy

5. Technology and Telehealth Experience

6. Additional Questions

7. References

Authorization