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Clinician's Circle application

This application is for clinicians only.

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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 21

Name

Question 3 of 21

Today's Date

Question 4 of 21

Email

Question 5 of 21

City, State, Country of Residence

Question 6 of 21

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

Question 7 of 21

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

Question 8 of 21

State(s) or Country of Licensure

Question 9 of 21

Years in Practice

Section 2

Practice Information

Question 11 of 21

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 12 of 21

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

Question 13 of 21

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

Question 14 of 21

Additional Certifications or Trainings

Section 3

AIMHC Clinician's Circle Interest

Question 16 of 21

How did you hear about the AI Mental Health Collective?

Question 17 of 21

Please share your LinkedIn and/or website. 

Question 18 of 21

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

Question 19 of 21

Any additional comments or questions?

Question 20 of 21

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

Thank You!

We will be in touch with you soon...please check your email spam folder over the next few days. 

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