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PERSONAL INFORMATION

Please complete all the fields below before submitting your application. Please be prepared to submit all necessary documentation when submitting your application. This includes a current copy of your Professional Liability insurance, a copy of current Professional license, a copy of your ID/DL, and your current Curriculum Vitae. If you are unable to upload your documents or are licensed in more than one state, you can email any supporting documents to PR@christiantherapistod.com
First Name *
Last Name *
Date *
Email *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone *
Upload Cover Letter
Upload Resume/CV *
Upload ID/DL *Please provide a copy of your State ID or drivers license.
Upload Malpractice Insurance *Please provide a current copy of your Professional Liability insurance with a Certificate showing the following information: - Name of policy holder - Name of policy carrier - Limits of liability - Expiration Date
Upload Copy of Professional License *Please provide a copy of your professional license.

Please provide your Licensing information. *
(example e.g., Psychologist, LCSW, LPC, etc.)
Do you have any experience with providing counseling online? If so, Please tell us about it. *
Why are you interested in providing counseling services online? *
Please share your approach to incorporating faith into one's counseling experience? Please provide some details about your counseling style and approach. *
Are you able to provide services in another language other than English? If so, which one(s).
Have you ever been subject to an investigation or review by your licensing board? If so, please provide details. *
Describe a situation - either work or personal - where you faced a major obstacle in your path to accomplishing a goal or commitment. How did you handle it and what was the ultimate outcome? *
How did you hear about Christian Therapist On Demand? *
Which mobile operating system do you use? *
AndroidIOSOther
Email
Email