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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.
1.First Name(Required.)
2.Middle Initial
3.Last Name(Required.)
4.What is your date of birth?(Required.)
Select the date below
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.)
Month
Year
Date
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?
Month
Year
Date
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?
Month
Year
Date
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.)
Month
Day
Year
Date