Pro Bono Counseling Project | Become a Volunteer Clinician

During the next 12 months I can commit to

Number of Pro Bono cases:

or Hours of Pro Bono Counseling:

About you

First Name: *

Last Name: *

Middle Name:

Prefix: *

Suffix:

Gender: *

Level of license: *

Contact information

E-mail Address: *

Business Phone: *

Mobile Phone:

Therapy Address

Street: *

City: *

State: *

Zip Code:

Mailing Address

Is this also your mailing address?:

Same

Street: *

City: *

State: *

Zip Code:

My Office is Wheelchair Accessible: *

Yes

I would Prefer to Meet with Clients: *

In my Office

At Another Location

Besides English, I also Speak:

I would like to participate in the following programs:

Jean Steirn Cancer Program -- Helping individuals and loved ones coping with a diagnosis of cancer.

Private Counseling for Public Service -- Helping service men and women and their loved ones.

Transition and Depression: Elderly and Underserved -- Reaching out to seniors.

Victims of Violence -- Linking victims and witnesses of violent crimes with therapy.

Caring for Caregivers -- Responding to the needs of those who are caring for loved ones with long term illnesses.

Parenting Alone: Building Healthy Families -- Supporting single parent families.

Comments:

Become a Volunteer Clinician