Mental Health Provider Questionnaire

Contact Info

Name*

First Last

Date of Birth*

Phone*

Email*

Address*

Street Address City ZIP Code

Tell us a little about yourself*

What do you do for self care?*

Why do you want to partner with Legacy of Hope Foundation ?*

Please list all relevant educational experiences*

School or Organization	Degree or Certificate Pursued	Level of Completion (Completed, X Credits/ Hours, etc)	Date(s) Attended

How many years of direct clinical experience do you have?*

Please enter a number greater than or equal to 1.

Do you have current and valid professional licensure to practice in a U.S. state?*

In which state(s) are you licensed? (select all that apply)*

What kind of clients do you typically serve?*

What kinds of therapy or modalities do you provide?*

Do you have a computer or phone with video chat capabilities?*

Do you have experience providing services through video chats/calls?*

What experience do you have with cultural competency and trauma-informed care?*