Become a Volunteer Clinician

Thank you for volunteering your professional services to Pro Bono Counseling (PBC).

To volunteer your therapeutic services with PBC, you must be currently licensed in the state of Maryland and have active liability insurance. All volunteers are also required to participate in a background check.

If you’re not currently licensed in Maryland, but want to stay connected and support our mission, please join our mailing list or consider making a gift. Thank you for your interest.

About You

Prefix

First

Middle

Last

Suffix

Prefix: Other

You are welcome to share your pronouns. Select all that apply.

shetheyhezePrefer not to respondother

Pronouns: Other?

Is there anything else you want us to know about how you would like to be addressed?

Contact Information

Preferred Email for PBC contact

Personal Email

Work Email

Preferred Phone for PBC contact

Mobile Phone

Business Phone for clients

Emergency Contacts

I voluntarily provide the below contact information and authorize Pro Bono Counseling and its representatives to contact the individuals below on my behalf in the event of an emergency or in the event of PBC and/or my clients are unable to reach me.

First Emergency Contact Name

First Emergency Contact Relationship

First Emergency Contact Mobile Phone

First Emergency Contact Email

First Emergency Contact Address

Second Emergency Contact Name

Second Emergency Contact Relationship

Second Emergency Contact Mobile Phone

Second Emergency Contact Email

Second Emergency Contact Address

Are you a supervised intern or do you have a graduate-level license? (LGPC, LGMFT, etc.)

Yes. I have a licensed supervisor providing my clinical supervision.No. I am fully licensed.

Supervision Information

Your Supervisor's Name

Supervision Start Date

Your Supervisor's Email

Supervision End Date (Anticipated)

Supervisor's License

If a current student, which university are you attending?

Please share your current university if it wasn't listed.

I plan to volunteer by:

Accepting a pro bono client for my own caseloadProviding clinical supervision to another volunteer

Those who provide clinical supervision to licensed graduate volunteers (LGPC, LGMFT, etc.) must be Board-approved to provide supervision. If your supervisee is a licensed graduate, please check the box below to confirm the statement.

I am a Board-approved supervisor

About Your Practice

Please share the URL to your practice's website, if any.

Type of License

Liability Insurance

Click "Choose File" to upload a copy of your liability insurance. If you prefer, you may instead submit a copy of your liability insurance to us by email: yswain@probonocounseling.org, Fax 410.825.1388 or mail: Pro Bono Counseling ATTN: Yolonda Nelson-Swain 5900 Metro Drive Baltimore, MD 21215

Additional Training and Certifications

Volunteer Commitment

I meet with clients

In my Office	At Another Location
Via Teletherapy	In Clients' Homes

My office is wheelchair accessible

Yes

I am available to meet with clients

WeekdaysEvenings (5pm or later)Weekends

Insurance

From time to time, when PBC receives calls from clients who have the means to pay for counseling through a combination of insurance and income, PBC may refer them to a PBC clinician. These referrals are not considered to be pro bono referrals. I accept

Aetna	Blue Cross Blue Shield
CIGNA	Kaiser
Medical Assistance	Medicare
Other	Tricare
United Healthcare	Wellpoint (formerly Amerigroup)

I can provide therapy to [Number of pro bono cases] at a time.

Number of pro bono cases:

I can work with:

Children	Adolescents
Adults	Couples
Families	Older Adults

I am competent providing counseling to Marylanders who are:

Arab, Middle-Eastern, or North AfricanAsianBi-racial or MultiracialBlack or African AmericanCaregiversDeaf or Hard of HearingGender Expansive or TransgenderHispanic or LatinoImmigrantsIndigenous or Native AmericanMenMilitary Members, Veterans, and their FamiliesSouth AsianWomenCompetency means: specific training, supervised clinical experience, or lived experience

I am competent providing counseling for people seeking care related to:

Attention Deficit Hyperactivity Disorder (ADHD)	Anger Management
Anxiety	Autism
Career Counseling	Depression
Domestic Violence	Eating Disorders
Educational Testing	Gender Identity
Grief/Loss	Long-Term Physical Illnesses (Including Cancer)
Medications	Obsessive Compulsive Thoughts/Behaviors
Parenting	Perinatal Mental Health
Psychological/Neuropsychological Assessments	Sexual Abuse
Sexual Orientation	Substance Use
Trauma

Competency means: specific training, supervised clinical experience, or lived experience

I have training in using or providing:

EMDRGender-Affirming Care Evaluations

I have training in using faith or spirituality based approaches:

YesNo

Which religious or spiritual approach do you utilize? Select all that apply

BuddhistCatholicChristianHinduJewishMormonMuslimOtherSpirituality

Spiritual approach: Other or anything else you would like to share?

Please let us know if you have other areas of competency or clients you would like to work with that are not listed above.

I am volunteering because of affiliation with the U. S. Public Health Service.

Yes, that is correct.No, I am not affiliated with the USPHS.

The USPHS has asked that PBC document your rank. Please share it here.

Language Access

I can provide therapy:

In English only

In English as well as the following languages I am fluent in

Besides English, I can provide therapy in

Other languages I can provide therapy in

PBC is able to offer interpreter services for clients who have Limited English Proficiency

I can work with Limited English Proficiency clients with the assistance of a PBC provided interpreter.I would like to receive training on working with interpreters so that I can work with Limited English Proficiency clients.

PBC can provide translation of documents for PBC clients. PBC also has a monthly peer support and consultation group for clinicians working with interpreters. Please email alexa@probonocounseling.org for more information on the consultation group.

Demographic Information

The following section of questions are related to your personal background, and are optional. This information is used when clients express a preference to be matched with a clinician from a specific background. We also use this information (in the aggregate) to understand the demographic profile of PBC volunteers as a whole.

How do you identify your race(s)? Select up to three and use 'Let Me Type' to enter any additional information.

Race: Please describe if you selected Let me type.

How do you identify your ethnicity?

Ethnicity: Please describe if you selected Another ethnicity not listed here (let me type)

*How do you identify your gender?

Gender: Please describe if you selected Let me type.

*Cisgender describes a person whose gender identity aligns with those typically associated with the sex assigned to them at birth. Transgender is an umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth. Definitions from the Human Rights Campaign.

What is your birth year?

Anything else you would like to share about your personal background?

Address Information

Therapy Address

Street Address

Address Line 2

City

State/Province/Region

Zip/Postal Code

Country

Mailing Address

Street Address

Address Line 2

City

State/Province/Region

Zip/Postal Code

Country

What motivated you to enroll with Pro Bono Counseling?

Other: Please describe below

Comments

Refer a Colleague

If you know a colleague who may also be interested in volunteering, please provide the contact, including name, email address or phone number, of licensed clinicians, including LG's who may be interested in joining Pro Bono Counseling.

Contact Information

Become a Volunteer Clinician

Thank you for volunteering your professional services to Pro Bono Counseling (PBC).

Become a Volunteer Clinician

Location / Contact

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