Become a Volunteer Clinician - Pro Bono Counseling Project

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
Caregiver Needs
Career Counseling
Domestic Violence
Eating disorders
Educational testing
EMDR
Faith-based
Gay/Lesbian/Bisexual
Gender Identity
Grief
Latinos
Medications
Military Members, Veterans, and their Families
Older Adults
Postpartum Depression
PTSD
Sexual abuse
Single Parenting
South Asians and Indians
Substance Abuse
Trauma
Victims of Crime/Violence
Other

If Other, please provide interest

During the next 12 Months, I can commit to

Number of Pro Bono cases:

About You

Name*

Prefix First Middle Last Suffix

Preferred Prefix

If you selected "Other", please enter your preferred prefix here.

Level of License*

Race/Ethnicity

Optional Information

Gender

Optional Information

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 Country

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

My Office is Wheelchair Accessible*

Yes
No

I would prefer to meet with clients*

In my Office
At Another Location
Via Teletherapy
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

Please provide two or more names, including email address and phone number, of licensed clinicians, including LG's who may be interested in joining the Pro Bono Counseling Project

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.

During the next 12 Months, I can commit to

About You

If student or graduate-level license

Contact Information