For Counselors We're glad you're here. We need dedicated, professional counselors. We're looking forward to learning about you. After you fill out this questionnaire we will carefully review it and get back to you with further information.Name* First Last Email* Enter Email Confirm Email Phone*Address* Licensing InformationAffirmation*YesNoOtherDo you affirm: that you are fully licensed in the U.S.; that you are not required to be supervised; and that you have at least 2000 client contact hours?Please Explain:*Licensing State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense Number*License Link*Please provide a direct link to the appropriate state agency website where your license can be searched and verified.Has your licensing board ever done a review or investigation on you?*YesNoDid it result in disciplinary action?*YesNoPlease Explain:*References* Provide at least 3 professional references (Name & email). The first must be a licensed mental health professional. Online CounselingHave you done any online counseling?*YesNoTell us about it:*What experience do you have? How long?Which services are you comfortable providing?* Online messaging Phone sessions Live chat Video chat Mark all that apply:Which characteristics apply to you?* Male Female Christian Non-Religious Gay Under 40 Over 40 Spanish Speaker Mark all that apply:List all the languages you can comfortably speak in counseling. If everything looks good we'll use the information below to to create your free counselor profile. Photo*Photos must be professional quality and in color.Designations* Please list all of your professional designations you would like listed with your name? Examples: "LCSW", "LPC", "CAC I", etc.Specialties* Please list all of your main areas of expertise you wanted listed on your profile. Examples: "Anxiety", "Depression", "Self-Esteem", "Addictions", " etc.About Me*Tell potential clients about you. Share anything from your interests, to your approach, to the types of clients you service.Personal Quote*If you only had 1 sentence to reach out to a potential client, what would it be?Years in practice:*School Attended:*Year Graduated:*TestimonialsIf you don't have any yet don't worry. We'll help you get some. If you do, please input them using the format below.Written by C.HJane has been very good about listening and providing feedback. There are many paths you can take for help but it is nice to know the options and help direct the progress you want to make. How did you hear about eTherapyPro?*Thanks for taking the time to provide us with this information. We'll be getting back to you soon. By clicking submit you affirm your understanding that if we invite you to join eTherapyPro you will not be an employee of eTherapyPro. You will be an independent contractor. You also affirm that you have read and agree to the terms and conditions of eTherapyPro.