MENTAL HEALTH PROVIDER QUESTIONNAIRE

Please list all relevant educational experiences*

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

Professional Background
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?*
- Yes
- No
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?*
- Yes
- No
Do you have experience providing services through video chats/calls?*
- Yes
- No
What experience do you have with cultural competency and trauma-informed care?*

Contact Info