Urgent Request for COVID-19 Mental Health Volunteers

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* 1. Please fill out your contact information

Name/Credentials

Company

City/Town

Email Address

Phone Number

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* 2. What is your preferred method of contact?

By email

By phone

By text

No preference

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* 3. What licenses and certifications do you have, and Which of the following Maine licenses do you hold CURRENTLY? (Please check all that apply)

MD/DO

Ph.D.

MSW/LCSW

Psychiatric Nurse

Psychiatric PA

PsyD

Current Certification(s)

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* 4. Which professional organizations do you belong to? (currently, in good standing)

Maine Association of Psychiatric Physicians

Maine Association of Social Workers

Maine Chapter, American Academy of Child and Adolescent Psychiatry

Maine Psychological Association

Maine Medical Association

Other If you are NOT currently a member in one of the above organizations, please list below the discipline in which you are licensed and your current Maine license number in that discipline:(please specify)

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* 5. Have you completed Red Cross Disaster Training or other type of Disaster Training?

Red Cross

Other

Please specify type of training if other

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* 6. Have you previously deployed or participated in the scene of an active disaster in Maine or elsewhere?

Yes

When/where were you deployed?

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* 7. How many hours per week can you volunteer?

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* 8. Desired Schedule (Check days/times available).

	8:00 a.m. to 12:00 noon	12:00 noon to 4:00 p.m.	4:00 p.m. to 8:00 p.m.
Monday	Monday 8:00 a.m. to 12:00 noon	Monday 12:00 noon to 4:00 p.m.	Monday 4:00 p.m. to 8:00 p.m.
Tuesday	Tuesday 8:00 a.m. to 12:00 noon	Tuesday 12:00 noon to 4:00 p.m.	Tuesday 4:00 p.m. to 8:00 p.m.
Wednesday	Wednesday 8:00 a.m. to 12:00 noon	Wednesday 12:00 noon to 4:00 p.m.	Wednesday 4:00 p.m. to 8:00 p.m.
Thursday	Thursday 8:00 a.m. to 12:00 noon	Thursday 12:00 noon to 4:00 p.m.	Thursday 4:00 p.m. to 8:00 p.m.
Friday	Friday 8:00 a.m. to 12:00 noon	Friday 12:00 noon to 4:00 p.m.	Friday 4:00 p.m. to 8:00 p.m.
Saturday	Saturday 8:00 a.m. to 12:00 noon	Saturday 12:00 noon to 4:00 p.m.	Saturday 4:00 p.m. to 8:00 p.m.
Sunday	Sunday 8:00 a.m. to 12:00 noon	Sunday 12:00 noon to 4:00 p.m.	Sunday 4:00 p.m. to 8:00 p.m.

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* 9. Frequency of volunteer availability

Weekly

Semi-weekly

Monthly