Boost! Intent to Apply

Thank you for your interest in applying to the Boost! Program!

Boost! accelerates the licensure of Master’s-level Social Workers, Counselors and Marriage and Family Therapists in Virginia by covering supervision costs. It is targeted to individuals who aspire to become licensed therapists and must pay for licensure-required supervision themselves. This includes those just starting to accrue Clinical and Supervision hours and individuals who have already begun supervision hours if they have completed less than 60% of the Clinical and Supervision hours required to become licensed as an LCSW, LPC or LMFT in Virginia.

This form should take you no more than 10 minutes to complete. Please note, the form will not automatically save, please be prepared to complete it all at once. VHCF will review the information you provide and will contact you, if you will be invited to apply.

Boost! program information including Participant Guidelines and FAQs can be found at vhcf.org/Boost200.

Question Title

1. First Name (Required.)

Question Title

2. Middle Initial

Question Title

3. Last Name (Required.)

Question Title

4. What is your date of birth? (Required.)

Select the date below

Date

Question Title

5. Email Address (One you check regularly. VHCF will contact you via email regarding your Intent to Apply/Application.) (Required.)

Question Title

6. Cell Phone Number (Required.)

Question Title

7. Home Street Address (Required.)

Question Title

8. City

Question Title

9. State (Required.)

Question Title

10. Zip Code (Required.)

Question Title

11. Gender Identity (Required.)

Question Title

12. Race (Required.)

Question Title

13. Ethnicity

Question Title

14. Are you a first-generation graduate? (Parent/guardian did not graduate from college) (Required.)

Question Title

15. Will you now, or in the near future (including the 2-year service commitment period), require employer Visa sponsorship? (Required.)

Question Title

16. Financial Information

Your Annual Salary ($)

Total Household Income($)

Current Student Loan Balance ($):

Question Title

17. Please indicate if you meet any of the Boost! Preferred Selection criteria below. Note: Interested candidates who do not meet any priority category noted below are also encouraged to apply. (Required.)

Person of Color

Fluently Bilingual (able to provide therapy in English and another language)

I work in Southwest Virginia, Southside Virginia, or another rural area of Virginia

I do not meet any of the Preferred Selection Criteria

Question Title

18. Name of Virginia University/College that issued your Master’s degree

I attended graduate school outside of Virginia. (Please provide the school name, city and state.)

Question Title

19. Please indicate below if you graduated or will graduate from a Master of Social Work (MSW), Master of Counseling (MC) or Master of Marriage and Family Therapy (MFT) Program? Note: To participate in Boost! you must hold an MSW , MC or MFT degree. (Required.)

Master of Social Work

Master of Counseling

Master of Marriage and Family Therapy

Question Title

20. Graduation Date (Required.)

	Month	Year
Date	Date Month menu	Date Year menu

Question Title

21. Have you submitted an application to the Virginia Department of Health Professions (DHP) to begin licensure-required Supervision? (Required.)

Yes

Question Title

22. If yes, when did you submit your application?

	Month	Year
Date	Date Month menu	Date Year menu

Question Title

23. Have you received approval from the DHP to begin Supervision? (Required.)

Yes

Question Title

24. If yes, what date did you receive approval by the DHP to begin Supervision?

	Month	Year
Date	Date Month menu	Date Year menu

Question Title

25. Current Supervisor Information (Required.)

Name

Email Address

Phone Number

Question Title

26. Additional Supervisor Information, if applicable

Name

Email Address

Phone Number

Question Title

27. How many supervision and clinical hours have you completed as of the date you are submitting this Intent to Apply? (Required.)

Supervision Hours (100 total hours for social workers; 200 total hours for Counselors and Marriage and Family Therapists)

Clinical Hours (3,000 total hours for social workers; 3,400 total hours for Counselors and Marriage and Family Therapists)

Question Title

28. Eligible applicants must be paying for or anticipate paying for most or all of their supervision hours. Select the option below that applies to you. (Required.)

I must pay for all of my Supervision hours

I must pay for most of my Supervision hours (Approximately 50% or more)

I do not pay for supervision at this time

Question Title

29. What hourly rate do you pay for your Supervision hours for Supervisor 1? (Required.)

Individual

Group

Question Title

30. What hourly rate do you pay for your Supervision hours for Supervisor 2, if applicable?

Individual

Group

Question Title

31. What is the organization name of your primary worksite? (Required.)

Question Title

32. What type of organization is your primary worksite? (Required.)

Question Title

33. Location (city/county) of your primary worksite (Required.)

Question Title

34. Estimated hours/week of licensure-required Direct Clinical hours at your primary worksite (Required.)

Question Title

35. What is the organization name of your secondary worksite, if applicable?

Question Title

36. What type of organization is your secondary worksite (if applicable)?

Question Title

37. Location (city/county) of your secondary worksite (if applicable)

Question Title

38. Estimated hours/week of licensure-required Direct Clinical hours at your secondary worksite (if applicable)

Question Title

39. How did you hear about Boost!?

Email from my graduate school

Social media from my graduate school

Professional association's email

Social media post from my professional association

Friend/classmate/colleague

Handshake

Other (please specify)

Question Title

40. Attestation: By checking each box and clicking “Submit,” you are attesting that you have completed this Intent to Apply accurately to the best of your ability. (Required.)

I understand and agree that in return for Boost! paying for my supervision hours, I commit to practicing as a licensed therapist in Virginia for two years (4,000 hours).

I will complete supervision hours at the average rate of 4 hours monthly for social workers or 8 hours monthly for counselors.

I do not have an active service commitment from other scholarships or loans.

I understand that if invited to apply for Boost!, I must submit the additional required documents including a personal statement, resume and recommendation form within 30 days of receiving that invitation.

Question Title

41. Please select the date you are submitting this Intent to Apply. (Required.)

	Month	Day	Year
Date	Date Month menu	Date Day menu	Date Year menu

Boost! Intent to Apply

Thank you for your interest in applying to the Boost! Program!

Question Title

* 1. First Name (Required.)

Question Title

* 2. Middle Initial

Question Title

* 3. Last Name (Required.)

Question Title

* 4. What is your date of birth? (Required.)

Question Title

* 5. Email Address (One you check regularly. VHCF will contact you via email regarding your Intent to Apply/Application.) (Required.)

Question Title

* 6. Cell Phone Number (Required.)

Question Title

* 7. Home Street Address (Required.)

Question Title

* 8. City

Question Title

* 9. State (Required.)

Question Title

* 10. Zip Code (Required.)

Question Title

* 11. Gender Identity (Required.)

Question Title

* 12. Race (Required.)

Question Title

* 13. Ethnicity

Question Title

* 14. Are you a first-generation graduate? (Parent/guardian did not graduate from college) (Required.)

Question Title

* 15. Will you now, or in the near future (including the 2-year service commitment period), require employer Visa sponsorship? (Required.)

Question Title

* 16. Financial Information

Question Title

* 17. Please indicate if you meet any of the Boost! Preferred Selection criteria below. Note: Interested candidates who do not meet any priority category noted below are also encouraged to apply. (Required.)

Question Title

* 18. Name of Virginia University/College that issued your Master’s degree

Question Title

* 19. Please indicate below if you graduated or will graduate from a Master of Social Work (MSW), Master of Counseling (MC) or Master of Marriage and Family Therapy (MFT) Program? Note: To participate in Boost! you must hold an MSW , MC or MFT degree. (Required.)

Question Title

* 20. Graduation Date (Required.)

Question Title

* 21. Have you submitted an application to the Virginia Department of Health Professions (DHP) to begin licensure-required Supervision? (Required.)

Question Title

* 22. If yes, when did you submit your application?

Question Title

* 23. Have you received approval from the DHP to begin Supervision? (Required.)

Question Title

* 24. If yes, what date did you receive approval by the DHP to begin Supervision?

Question Title

* 25. Current Supervisor Information (Required.)

Question Title

* 26. Additional Supervisor Information, if applicable

Question Title

* 27. How many supervision and clinical hours have you completed as of the date you are submitting this Intent to Apply? (Required.)

Question Title

* 28. Eligible applicants must be paying for or anticipate paying for most or all of their supervision hours. Select the option below that applies to you. (Required.)

Question Title

* 29. What hourly rate do you pay for your Supervision hours for Supervisor 1? (Required.)

Question Title

* 30. What hourly rate do you pay for your Supervision hours for Supervisor 2, if applicable?

Question Title

* 31. What is the organization name of your primary worksite? (Required.)

Question Title

* 32. What type of organization is your primary worksite? (Required.)

Question Title

* 33. Location (city/county) of your primary worksite (Required.)

Question Title

* 34. Estimated hours/week of licensure-required Direct Clinical hours at your primary worksite (Required.)

Question Title

* 35. What is the organization name of your secondary worksite, if applicable?

Question Title

* 36. What type of organization is your secondary worksite (if applicable)?

Question Title

* 37. Location (city/county) of your secondary worksite (if applicable)

Question Title

* 38. Estimated hours/week of licensure-required Direct Clinical hours at your secondary worksite (if applicable)

Question Title

* 39. How did you hear about Boost!?

1. First Name (Required.)

2. Middle Initial

3. Last Name (Required.)

4. What is your date of birth? (Required.)

5. Email Address (One you check regularly. VHCF will contact you via email regarding your Intent to Apply/Application.) (Required.)

6. Cell Phone Number (Required.)

7. Home Street Address (Required.)

8. City

9. State (Required.)

10. Zip Code (Required.)

11. Gender Identity (Required.)

12. Race (Required.)

13. Ethnicity

14. Are you a first-generation graduate? (Parent/guardian did not graduate from college) (Required.)

15. Will you now, or in the near future (including the 2-year service commitment period), require employer Visa sponsorship? (Required.)

16. Financial Information

17. Please indicate if you meet any of the Boost! Preferred Selection criteria below. Note: Interested candidates who do not meet any priority category noted below are also encouraged to apply. (Required.)

18. Name of Virginia University/College that issued your Master’s degree

19. Please indicate below if you graduated or will graduate from a Master of Social Work (MSW), Master of Counseling (MC) or Master of Marriage and Family Therapy (MFT) Program? Note: To participate in Boost! you must hold an MSW , MC or MFT degree. (Required.)

20. Graduation Date (Required.)

21. Have you submitted an application to the Virginia Department of Health Professions (DHP) to begin licensure-required Supervision? (Required.)

22. If yes, when did you submit your application?

23. Have you received approval from the DHP to begin Supervision? (Required.)

24. If yes, what date did you receive approval by the DHP to begin Supervision?

25. Current Supervisor Information (Required.)

26. Additional Supervisor Information, if applicable

27. How many supervision and clinical hours have you completed as of the date you are submitting this Intent to Apply? (Required.)

28. Eligible applicants must be paying for or anticipate paying for most or all of their supervision hours. Select the option below that applies to you. (Required.)

29. What hourly rate do you pay for your Supervision hours for Supervisor 1? (Required.)

30. What hourly rate do you pay for your Supervision hours for Supervisor 2, if applicable?

31. What is the organization name of your primary worksite? (Required.)

32. What type of organization is your primary worksite? (Required.)

33. Location (city/county) of your primary worksite (Required.)

34. Estimated hours/week of licensure-required Direct Clinical hours at your primary worksite (Required.)

35. What is the organization name of your secondary worksite, if applicable?

36. What type of organization is your secondary worksite (if applicable)?

37. Location (city/county) of your secondary worksite (if applicable)

38. Estimated hours/week of licensure-required Direct Clinical hours at your secondary worksite (if applicable)

39. How did you hear about Boost!?

40. Attestation: By checking each box and clicking “Submit,” you are attesting that you have completed this Intent to Apply accurately to the best of your ability. (Required.)

41. Please select the date you are submitting this Intent to Apply. (Required.)