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Clinician's Circle application

This application is for clinicians only.

Click the button below to start.

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Section 1

The AI Mental Health Collective is for mental health professionals and clinicians (therapists, counselors, psychologists, psychiatrists, social workers).

Question 2 of 24

Name

Question 3 of 24

Title (Psychologist, LMFT, LPC, MD, LCSW, etc)

Question 4 of 24

Today's Date

Question 5 of 24

Your Professional Email

Question 6 of 24

City of Residence

Question 7 of 24

State/Region of Residence

Question 8 of 24

Country of Residence

Question 9 of 24

Are you currently a clinician (actively working with clients in some capacity)?

Question 10 of 24

License Number (include all, ie: LPC, MD, LMFT, Psychologist, LCSW, etc).

Question 11 of 24

State(s) or Country of Licensure

Question 12 of 24

Years in Practice

Section 2

Practice Information

Question 14 of 24

Current Practice Setting

A

Private Practice (Solo)

B

Private Practice (Group)

C

Community Mental Health

D

Hospital/Medical Center

E

School or University Counseling Center

F

EAP

G

Other

Question 15 of 24

Demographic of clients you work with (adults, couples, children, etc)

Question 16 of 24

Treatment Modalities/Approaches (ie: CBT, Narrative, Family Systems, etc)

Question 17 of 24

Additional Certifications or Trainings

Section 3

AIMHC Clinician's Circle Interest

Question 19 of 24

How did you hear about the AI Mental Health Collective?

Question 20 of 24

Please share your LinkedIn and/or website. 

Question 21 of 24

Almost done with the application process!...What interests you about joining the Collective?

Question 22 of 24

Any additional comments or questions?

Question 23 of 24

By writing my full name I attest that the information provided is true.

Last Step!

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