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Become a Volunteer Clinician
The Pro Bono Counseling Project
2020-03-26T13:44:56-04:00
Thank you for volunteering your professional services to the Pro Bono Counseling Project.
Please complete this form and send a copy of your liability insurance to us by fax, email or mail, or upload at the bottom of this form.
I agree to provide pro bono mental health care to
*
Children
Youth
Adults
Couples
Families
Groups
(check all that apply)
My areas/populations of interest are:
*
Anxiety disorders
Cancer/Long-term Physical Illnesses
Career Counseling
Caregiver Needs
Christian Faith Based Healing
Depression Disorders
Domestic Violence
Eating disorders
Educational testing
EMDR
Faith-based
Gay/Lesbian/Bisexual Mental Health
Gender Identity
Grief/Loss
HIV/Aids Support
Latinos
Medications
Men's Mental Health
Military Members, Veterans, and their Families
Older Adults
Parenting
Postpartum Depression
PTSD
Sexual abuse
South Asians and Indians
Spirituality
Substance Abuse
Telepsychology
Transgender Mental Health
Trauma
Victims of Crime/Violence
Women's Mental Health
Other
If Other, please provide interest
During the next 12 months, I can commit to
Number of pro bono cases:
- None -
One
Two
Multiple
About You
Name
*
Mr.
Mrs.
Miss
Ms.
Mx.
Dr.
Rev.
Prof.
Rabbi
Other
Prefix
First
Middle
Last
Suffix
Preferred Prefix
If you selected "Other", please enter your preferred prefix here.
Level of License
*
- Select -
APRN-PHM
CRNP-PMH
EDD
LCSW-C
LMSW
LCMFT
LCPC
LGPC
MD
PHD
PSYD
Reg Psych Associate
Supervised Intern
LGMFT
LGPC Candidate
LMSW Candidate
Additional Training and Certifications
Race/Ethnicity
Gender
If student or graduate-level license
Supervisor Name
Supervisor's License
Contact Information
Email
*
Business Phone
*
Mobile Phone
Therapy Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Mailing Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
My office is wheelchair accessible
*
Yes
No
I would prefer to meet with clients
*
In my Office
At Another Location
Via Teletherapy
Via Telephone
In Clients' Homes
I am available to meet with clients
Weekday Daytime
Weekday Evenings (6 pm or later)
Saturdays
Sundays
Supervisor
I am available to be a Supervisor for 1 hour per week
I have office space for graduate students
Besides English, I also speak
Insurance
From time to time, when PBCP receives calls from clients who have the means to pay for counseling through a combination of insurance and income, PBCP may refer them to a PBCP clinician. These referrals are not considered to be pro bono referrals. I accept
Aetna
Amerigroup
Blue Cross Blue Shield
CIGNA
Kaiser
Tricare
United Healthcare
Other
If Other, please tell us the provider.
How did you hear about the Pro Bono Counseling Project?
Comments
Refer a Colleague
If you know a colleague who may also be interested in volunteering, please provide the name, including email address and phone number, of licensed clinicians, including LG's who may be interested in joining the Pro Bono Counseling Project.
File Upload
Click here to upload a copy of your liability insurance.
Drop files here or
Accepted file types: pdf, jpg, png.