First Name
Last Name
Email
*
Phone
*
Where do you currently reside?
Location you are interested in working at? (Ramsey, Montclair, Hoboken)
What state and license type do you hold? What is your license number?
How did you hear about us?
Google Search
Referred by someone (if comfortable, please share who below)
Instagram
TikTok
LinkedIn
Our website
Indeed
Other (Specify below)
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Are you currently affiliated with or contracted by any third-party mental health platforms (e.g., Headway, Alma) or other private practices? If yes, please provide details on the nature of your affiliation and any contractual obligations.
Please specify here
Share the link to your Psychology Today profile and/or your LinkedIN if applicable.
Ages of Preferred Clients
Children (Age2-8)
Children (Age 9-12)
Adolescents (Age 13-18)
Young Adult (19-25)
Adult (26-64)
Seniors (65 and up)
Share a short bio of your professional work since completing your masters degree.
What are your areas of specialization? (Choose up to 3)
Mood Disorders
Grief Counseling
Personality Disorders
Trauma/PTSD
Children or Teens
Substance Use Disorders
Addiction and Co Morbidities
Couples Counseling
Family Counseling
Group Therapy
Sexual Issues
Self Esteem/Self Worth
Autism/ADHD
Parenting/Co Parenting
Divorce Recovery
Divorce Mediation
High Risk/Crisis Counseling
Chronic Illness
Lifeskills Development
Executive Coaching
Career Counseling
Other
Describe in 3-5 brief steps, the typical therapeutic process your clients will experience with you on the way to reaching their goals. (Ex. 1. Dynamic Assessment 2. Aligning History 3. Tools 4. Putting it to Practice 5. Feedback)
What Post-Masters training or certifications have you completed?
Attach your resume (PDF, DOC)
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