Application Type
Licensed Counselor
Prefix
Mr.
Mrs.
Ms.
Dr.
PhD.
PsyD.
Prof.
Other
Name
*
First Name
Last Name
Gender
*
Email
*
Mobile Phone
*
(###)
###
####
Work Phone
(###)
###
####
Are You Part of a Group Practice?
*
Name of Group Practice
Office Main Line
(###)
###
####
Supervisor Name
First Name
Last Name
Supervisor Email
Supervisor Direct Line
(###)
###
####
Name of Private Practice
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
State Certified for Practice
*
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Delaware - DE
District of Columbia - DC
Florida - FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Additional State Certified to Practice2
N/A
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Delaware - DE
District of Columbia - DC
Florida - FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Additional State Certified for Practice3
N/A
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Delaware - DE
District of Columbia - DC
Florida - FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Years of Experience as Counselor
*
License Type
*
LAC
LCMHC
LCSW
LIMPH
LMFT
LMHC
LMHP
LPC
LPCC
LPC-MH
LPC-MHSP
LPCMH
LPCS
NCC
License Number
*
Additional License(s) & Number(s)
Counseling Modality
*
Adlerian
Attachment
Biofeedback
CBT
DBT
EFT
EMDR
Family Systems
Gestalt
Gottman
IFST
Jungian
MFT
Narrative
Neurofeedback
Parent Child
Person Centered
Play
Psychoanalytic
Psychodynamic
Restoration Therapy
SFT
Somatic
Strengths Based
Structural
Trauma
TFCBT
Other (Specify Below)
Additional Modalities
Demographics Served
*
(check all that apply)
Counseling Setting(s)
*
(check all that apply)
Counseling Duration
*
(check all that apply)
Frequency
*
(check all that apply)
Session Duration
*
(check all that apply)
Willing to Offer Pro Bono/Reduced Fee?
*
Yes
No
How Did You Hear About Us?
*
Why Do You Want to be a Provider with Pastoral Transitions?
*
Supplemental Info
Additional details pertaining to any question on this application.
Anything Else We Should Know About You?
(e.g., your family or background, hobbies, passions, talents, accomplishments, involvements, etc.)
