* Required Field

ABOUT YOU:
Prefix:*
First Name:*
Middle Name:
Last Name:*
Suffix:
Gender:*
 

Race:*
Besides English, I also speak:
  Spanish   ASL
Other

ABOUT YOUR LICENSE & EXPERIENCE:
License Level:*
License Number:*
License Expires:*
Experience:* (# of Years)
Do you have professional liability insurance?*

Please send copies of your Ohio
professional license and professional
liability insurance to the PBCP contact.

Yes  
No (This will not prevent
          you from volunteering)

If Yes, when does it expire?*

 

Are you a Graduate Student in a mental health discipline?*
  Yes   No
If you are not independently licensed, you will need a supervisor who is.  Please complete his/her information below:
   Supervisor Name:
   Supervisor Phone:
   Supervisor E-mail:
   Supervisor License Level:
   Supervisor License Number:
   Supervisor License Expires:

CONTACT INFORMATION:
E-mail Address:*
Business Phone:*
Cell Phone:
Fax Number:

THERAPY ADDRESS:
Street Address:*
Suite #:
City, State  ZIP:* ,  
County:*

Is your office wheelchair accessible?*
  Yes   No
Is your office on a bus line?*
  Yes   No

MAILING ADDRESS (click to copy from above):
Street Address:*
Address (Line 2):
City, State  ZIP:* ,  
County:*
 
I would prefer to meet with clients:*
 
I am available for counseling:*
  morning
afternoon
evening
weekend
I am able to provide counseling to the following populations:*
Adults
Young Adults (18-26)
Older Adults (65+)
LGBTQ
Caregivers

I am able to provide counseling to:
Individuals
Couples
Families
Groups

I am able to provide counseling for the following concerns:
Anxiety
Depression
Postpartum depression
Anger management
Life stress
Domestic violence
Eating disorders
Long-term physical illness
Marital/Partner counseling
Sexual abuse
Physical abuse
PTSD
Sexuality
Gender issues
Grief
Spiritual issues
Loss of employment
Victim of crime
Witness to crime
Family issues
Other

I am able to provide the following interventions:
CBT   EMDR   Other

 
ABOUT MY CASELOAD:
We are asking each volunteer to see a minimum of one client per year.  However, since the amount of time required for each case may vary, we hope you will be willing to see another client once your existing case closes.

If you are willing to see additional clients within a year, indicate how many you would like on your caseload at any given time:

When I accept a new client, I prefer to:

How did you hear about the Pro Bono Counseling Program? 


Questions, Comments, or Suggestions:

After submitting this form, please remember to send copies of your Ohio professional license and professional liability insurance to us by fax, e-mail, or mail.

MHAFC publishes the names of volunteers in The Advocate newsletter.  If you do NOT wish to be acknowledged, please contact the PBCP Director.
 
Verification Word:  To help us reduce fraudulent submissions, please type the word shown below into the box provided:

(lowercase or uppercase)