MH network :

Salutation:

First Name:

Middle Initial:

Last Name:

Home Phone:

Cell Phone:

Work Phone:

Primary Email Address:

Secondary Email Address:

Do you speak Spanish?

  Yes No

License:

  Psychologist Medical MFT LCSW LEP LPC Other

State granting this license:

Select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Northern Marianas Palau Puerto Rico Virgin Islands Central and South America (Armed Forces) Europe (Armed Forces) Pacific (Armed Forces)

License Expiration Date:

License Number/NPI/UPIN:

Highest Relevant Degree:

PhD MD PsyD EdD DNP/DNSc MSW MA/MS MSN

Education-based Subfield or Subspecialty:

Addiction Child & Adolescent Clinical Clinical Neurophysiology Counseling Cognitive/Perceptual Developmental Forensic Geriatric Hospice & Palliative Marriage/Family Neuropsychology Pain Psychiatric/Mental Health Psychosomatic Rehabilitation Research School Sleep

Name of School or Institute granting this Degree:

Professional Affiliations and Certifications:

Diplomate in Clinical Social Work (DCSW)

American Board of Psychiatry &
      Neurology (Board Certified)

Psychiatric/Mental Health Nurse
      Practitioner (PMHNP)

Clinical Nurse Specialist (CNS)

American Psychological Association Leadership

American Psychiatric Association Leadership

Please indicate if you have a practice or research focus in any of the following "disorder" categories:

Anxiety

PTSD

Mood

Bipolar

Psychotic

Substance Abuse

Cognitive

Developmental

Axis II diagnoses

Based on the descriptions above, please indicate which of the following services you would be willing to perform for our clients:

Full Evaluation

Critical Review of Mental Health
      Records

Forensic Consultation

Interview of a Client

Ongoing Counseling

Practice 1 (Preferred Place of Contact)

Facility/ Practice Name:

Street Address:

Street Address line 2:

City:

State:

Select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Northern Marianas Palau Puerto Rico Virgin Islands Central and South America (Armed Forces) Europe (Armed Forces) Pacific (Armed Forces)

Zip Code:

Phone Number:

Phone Extension:

Fax:

Facility/ Practice Name:

Street Address:

Street Address line 2:

City:

State:

Select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Northern Marianas Palau Puerto Rico Virgin Islands Central and South America (Armed Forces) Europe (Armed Forces) Pacific (Armed Forces)

Zip Code:

Phone Number:

Phone Extension:

Fax:

Facility/ Practice Name:

Street Address:

Street Address line 2:

City:

State:

Select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Northern Marianas Palau Puerto Rico Virgin Islands Central and South America (Armed Forces) Europe (Armed Forces) Pacific (Armed Forces)

Zip Code:

Phone Number:

Phone Extension:

Fax:

With which Practice above is this Assistant associated?

1 2 3

First Name:

Last Name:

Phone Number:

Phone Extension:

Email:

If you want to clarify your above responses, or if there is anything else we should know about you, please tell us here:

We will review your information, and ensure our program is an appropriate volunteer opportunity based on your qualifications. We will confirm receipt of your information by email within one week, and contact you by email or phone for clarification if necessary. Your information will be kept in an internal database of volunteers, but not publicly posted or shared. Please note: We are unable to ensure that one of our cases will present an appropriate volunteer opportunity for you.