Apply as a Counselor

Join our network of compassionate professionals making mental health care accessible to those who need it most. Complete this application to be considered for the Counselor Fund.

A. Basic Contact Information

First Name *

Last Name *

Email Address *

Phone Number

Practice / Business Name *

Business Address - Street *

Business Address - Suite / Unit

City *

State *

ZIP Code *

B. Professional Licensure

License Type *

License Number *

License State / Jurisdiction *

Years in Practice *

Certifications (if any)

List any additional certifications you hold

C. Mission & Values

What is the mission or purpose of your practice? *

What are your core values as a counselor?

What motivates you most in your practice?

D. Populations You Serve

What client populations do you currently serve? *

Include age ranges, presenting issues, and demographics

Describe your experience serving diverse or underserved clients. *

E. Access & Low-Fee Work

Have you previously worked with clients who could not pay full fees? *

F. How the Fund Expands Your Capacity

Which client populations would you be able to serve with support from the Counselor Fund that you currently cannot? *

How many additional clients do you anticipate serving through the Fund? *

How many low-fee clients are you currently able to take on if selected? *

How will participation in the Counselor Fund advance or empower your mission? *

What are your plans for growth or outreach over the next 1–3 years?

G. Ethics & Accountability

Have you ever had any disciplinary or licensing complaints or actions? *

H. Consent & Agreement

I affirm that the information provided is accurate and understand that the Counselor Fund may contact me for verification. *

I consent to being contacted regarding participation and future opportunities. *