ECW - Therapist Application | Elite Practice Management Solutions

Name *

Email address *

Phone Number *

Professional License Type *

Licensed Professional Counselor (LPC)
Licensed Independent Social Worker – Clinical Practice (LISW-CP)
Licensed Marriage and Family Therapist (LMFT)
Other

Professional License Number *

Current License Status *

Active – Independently Licensed
Active – Associate/Provisional License
License Application Pending
Inactive or Expired
Other

Years of Clinical Experience *

Less than 1 year
1–2 years
3-5 years
6-10 years
More than 10 years

Clinical Specialties / Areas of Experience *

Anxiety Disorders
Depression and Mood Disorders
Trauma and PTSD
Domestic Violence / Intimate Partner Violence
Grief and Loss
Relationship and Marital Issues
Family Conflict
Child and Adolescent Mental Health
Substance Use Disorders
Stress Management and Life Transitions
Behavioral Issues
Other

Telehealth Availability, *

Weekday Mornings
Weekday Afternoons
Weekday Evenings
Saturday Mornings
Saturday Afternoons
Sunday Availability
Flexible / Varies

Preferred Weekly Caseload. *

1-5 clients per week
6-10 clients per week
11-15 clients per week
16-20 clients per week
20 or more clients per week
Flexible/To Be Determined

Client Age Groups You Are Qualified to Treat *

Young Children (Ages 3–5)
Children (Ages 6–12)
Adolescents (Ages 13–17)
Young Adults (Ages 18–25)
Adults (Ages 26–64)
Older Adults (Ages 65+)

Therapeutic Approaches / Treatment Modalities *

Cognitive Behavioral Therapy (CBT)
Dialectical Behavior Therapy (DBT)
Trauma-Focused CBT (TF-CBT)
Solution-Focused Brief Therapy (SFBT)
Motivational Interviewing (MI)
Person-Centered Therapy
Psychodynamic Therapy
Acceptance and Commitment Therapy (ACT)
Family Systems Therapy
Couples Counseling
Play Therapy
Eye Movement Desensitization and Reprocessing (EMDR)
Other

Resume Upload *

1099 Independent Contractor Acknowledgment *

Yes, I understand and am interested in a 1099 independent contractor opportunity.
No, I am only interested in a W-2 employee position.
I would like additional information before deciding.

Applicant Acknowledgment *

I understand that Elite Counseling & Wellness is currently in the practice development and insurance credentialing phase.
I would like more information before proceeding.

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