Name
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First Name
Last Name
Phone
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Email
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How did you hear about this position with Colorado Therapy Collective? (ie google search, Indeed, Linkedin, Masters program, a colleague, etc)
Current city & state of residence
Do you hold a Masters or Doctorate Degree in Marriage and Family Therapy, Counseling, Psychology, or Social Work from an accredited university?
Yes
No
I am currently enrolled in a graduate program
Do you hold an active Colorado license in a mental health field, including registration with the Colorado Department of Regulatory Agencies (DORA)?
Yes
No
I am provisionally licensed in Colorado (MFTC, LPCC, LSW, etc)
I am licensed in a different state
I am currently a graduate student
Which licensure(s) do you hold with the state of Colorado? (ie LPC, LPCC, LCSW, LMFT, MFTC, etc)
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Have you completed an ICEEFT approved Emotionally Focused Therapy (EFT) Externship?
Yes
No
I am currently registered for an EFT Externship
Please list any trainings or certifications you have completed in other therapy modalities/specialties (examples EMDR, DBT, Sex Therapy, etc)
Please tell us briefly about your areas of interest, previous work experience, and any other information that informs us about your ability to work with individuals, couples, and/or families.
What is your favorite population to work with? Please describe your ideal client.
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What is your comfort level working with couples? How would you feel about that caseload full time?
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Please describe how you approach couples from an attachment perspective. Please also describe your understanding of what would NOT be an attachment approach to couple distress and challenges.
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Do you have availability and willingness to work at least 18 hours/week over 3-5 days per week, including at least 2 evenings until 8pm?
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Ideally, how many client hours would you like per week?
What interests you about Colorado Therapy Collective specifically?
Please tell us briefly about yourself. How would your colleagues and/or clients describe you?:
Would you consider yourself LGBTQIA+ affirmative? If so, what does that mean to you?
Please describe your experience working with racially and culturally diverse clients.
Please provide 3 professional references, their contact information and relationship to you.
Has any claim or suit ever been brought against you for alleged malpractice or professional liability, or are you aware of any incident or existing circumstances that might reasonably lead to a claim or suit?
Have you ever been refused coverage for professional liability or malpractice insurance or has your malpractice or professional liability insurance ever been canceled or declined for renewal (non-renewed)?
Have you ever been convicted of a misdemeanor or felony?
Have any complaints ever been filed against you or have there ever been any formal or informal investigations or inquiries opened with a peer review committee or an ethics committee of a professional association, hospital, health care facility, or any other governmental or private entity?
Have you ever been vicariously or directly accused of sexual misconduct or any professional impropriety?
Do you know of any reason why you cannot comply with the legal, ethical, or professional standards set by law, by regulation, by a peer review committee or by an applicable code of ethics in any jurisdiction where you provide services?
If you answered 'Yes' to any of the above questions, please provide additional information below:
