Name
*
First Name
Last Name
Preferred eTherapyCare Email
*
Phone
*
(###)
###
####
Emergency Contact
*
Who can we reach in the event of emergency
First Name
Last Name
Preferred Start Date
MM
DD
YYYY
Home Address
*
For Corporate Info only, only state will be shared publicly.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What are your standing hours of availablility?
*
You're in control of your schedule. Clients prefer regular recurring session times. We will build your available schedule off of the schedule provided here. Keep in mind sessions run in 50-min blocks.
Schedule Preference
*
Do you prefer to run sessions back-to-back or you prefer a break in-between?
All States You Want to See Clients From?
*
Interested in offering group therapy? Include topic, description, dates & times, fee, max group size:
I have malpractice insurance.
*
All States Where Licensed & License Number:
Therapeutic Approach
50-minute Session Rate
*
Interested in Rate Data?
We will run in-kind comps for self-pay rates in your zip
You Work With:
*
I qualify and I am interested in Volunteering 1-hour per week as an Intern Supervisor
Preferred Payment Method
*
Preferred Pay Frequency
We want to highlight our Clinicians & their interests on our PodCast, would you be interested in joining?
Interested in selling your book, workbook, digital downloads, etc in our Store?
Other
