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  eTherapy Provider Application

Name
Address
City, State & Zip 
Voicemail-individual
Voicemail-office
Pager
Email
Years in practice
Degree 1 - School
Degree 2 - School
Degree3 - School
Licenses
Certification
Languages other than English
Gender (optional, but helpful for specific requests)
Ethnicity (optional,  but helpful for specific requests)

Has your license or certification ever been revoked or suspended, or have you ever received any disciplinary action from a licensing body?

(If yes, submit detailed explanation and verification of reinstatement.)

 Yes No
Complete the next section only if you are applying to become an online provider with our network. If you are registering for training, do not complete this section.

Services Offered

Adolescent  Employment Parenting
Addictions Ethnicity/Multi-cultural Personality Disorders
Alternative Lifestyles Family  PTSD
Anxiety/Panic Forensics

Religious Issues
Children's Issues  Gay/Lesbian Issues Self Esteem/Growth
Co-dependency Geriatrics Sexual Abuse
Crisis Counseling Grief/Loss Spiritual Issues
Depression Issues of abuse Step/Blended Families
Disabilities Life Transitions Stress Management
DID Mediation Terminally Ill
Divorce Counseling Meditation Twelve Step
Eating Disorders Men's Issues Women's Issues
EMDR Pain Management
Other Other Other

Days and hours available Monday - Sunday

Please write a  paragraph of 150-200 words describing your personal and professional interests. (to be used in reviewing your application only.)

List three (3) personal and three (3) professional references -(Include name, address phone number and email)

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