FCOS Therapist Application Survey

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* 1. Please provide the following information

Name

Email Address

Phone Number

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* 2. How many hours per week are you interested in seeing clients?

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* 3. I am available to see clients weekly on the following days and between the following hours.

	8am-noon	Noon-4pm	4pm-9pm
Mondays	Mondays 8am-noon	Mondays Noon-4pm	Mondays 4pm-9pm
Tuesdays	Tuesdays 8am-noon	Tuesdays Noon-4pm	Tuesdays 4pm-9pm
Wednesdays	Wednesdays 8am-noon	Wednesdays Noon-4pm	Wednesdays 4pm-9pm
Thursdays	Thursdays 8am-noon	Thursdays Noon-4pm	Thursdays 4pm-9pm
Fridays	Fridays 8am-noon	Fridays Noon-4pm	Fridays 4pm-9pm
Saturdays	Saturdays 8am-noon	Saturdays Noon-4pm	Saturdays 4pm-9pm
Sundays	Sundays 8am-noon	Sundays Noon-4pm	Sundays 4pm-9pm

I am interested in working ________ hours per week.
Other times (please specify)

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* 4. If licensed in Virginia as an LPC, LCSW, LMFT, or clinical psychologist

License type & Number

Date initially licensed

Years of post-licensure experience in a counseling field

I am credentialed with the following companies:

Please list any complaints made against you with the VA Bd of Counseling

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* 5. Please indicate the ages you are trained and interested in working with.

	Trained & experienced	Interested in working with
2-6	2-6 Trained & experienced	2-6 Interested in working with
6-11	6-11 Trained & experienced	6-11 Interested in working with
11-18	11-18 Trained & experienced	11-18 Interested in working with
19-26	19-26 Trained & experienced	19-26 Interested in working with
Adults	Adults Trained & experienced	Adults Interested in working with
Geriatric	Geriatric Trained & experienced	Geriatric Interested in working with

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* 6. Diagnoses Experience & Interests

	Experienced with	Would like to work with	Plan to take additional training
Anxiety	Anxiety Experienced with	Anxiety Would like to work with	Anxiety Plan to take additional training	Anxiety
Depression	Depression Experienced with	Depression Would like to work with	Depression Plan to take additional training	Depression
Bipolar	Bipolar Experienced with	Bipolar Would like to work with	Bipolar Plan to take additional training	Bipolar
Serious Mental Illness	Serious Mental Illness Experienced with	Serious Mental Illness Would like to work with	Serious Mental Illness Plan to take additional training	Serious Mental Illness
Trauma/PTSD	Trauma/PTSD Experienced with	Trauma/PTSD Would like to work with	Trauma/PTSD Plan to take additional training	Trauma/PTSD
Childhood trauma	Childhood trauma Experienced with	Childhood trauma Would like to work with	Childhood trauma Plan to take additional training	Childhood trauma
Developmental Disorders	Developmental Disorders Experienced with	Developmental Disorders Would like to work with	Developmental Disorders Plan to take additional training	Developmental Disorders
Addictions (Alcohol/ Substance Abuse)	Addictions (Alcohol/ Substance Abuse) Experienced with	Addictions (Alcohol/ Substance Abuse) Would like to work with	Addictions (Alcohol/ Substance Abuse) Plan to take additional training	Addictions (Alcohol/ Substance Abuse)
OCD	OCD Experienced with	OCD Would like to work with	OCD Plan to take additional training	OCD
Eating disorders	Eating disorders Experienced with	Eating disorders Would like to work with	Eating disorders Plan to take additional training	Eating disorders
Self harm	Self harm Experienced with	Self harm Would like to work with	Self harm Plan to take additional training	Self harm
Life transitions	Life transitions Experienced with	Life transitions Would like to work with	Life transitions Plan to take additional training	Life transitions
Geriatric issues	Geriatric issues Experienced with	Geriatric issues Would like to work with	Geriatric issues Plan to take additional training	Geriatric issues
Health issues	Health issues Experienced with	Health issues Would like to work with	Health issues Plan to take additional training	Health issues
Families	Families Experienced with	Families Would like to work with	Families Plan to take additional training	Families
Couples	Couples Experienced with	Couples Would like to work with	Couples Plan to take additional training	Couples
Military Issues	Military Issues Experienced with	Military Issues Would like to work with	Military Issues Plan to take additional training	Military Issues
Parenting	Parenting Experienced with	Parenting Would like to work with	Parenting Plan to take additional training	Parenting
Divorce Discernment	Divorce Discernment Experienced with	Divorce Discernment Would like to work with	Divorce Discernment Plan to take additional training	Divorce Discernment
Divorce Support	Divorce Support Experienced with	Divorce Support Would like to work with	Divorce Support Plan to take additional training	Divorce Support

Other areas not listed (please specify)

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* 7. Availability to start

Immediately

Within 4 weeks

Other (please specify)

FCOS Therapist Application

Question Title

* 1. Please provide the following information

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* 2. How many hours per week are you interested in seeing clients?

Question Title

* 3. I am available to see clients weekly on the following days and between the following hours.

Question Title

* 4. If licensed in Virginia as an LPC, LCSW, LMFT, or clinical psychologist

Question Title

* 5. Please indicate the ages you are trained and interested in working with.

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* 6. Diagnoses Experience & Interests

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* 7. Availability to start

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* 8. What aspects or areas of counseling are you passionate about?

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* 9. What areas of counseling are you interested in gaining additional training?