Name *

First Name

Last Name

Phone

(###)

###

####

Are you a Community Agency or Private Practice? *

Community Agency

Private Practice

Both (Work in both settings)

What license do you hold? *

Licensed Professional Counselor (LPC or variation of LCPC etc)

LMHC

Licensed Clinical Social Worker (LCSW)

Licensed Marriage and Family Therapist (LMFT)

Licensed Associate Counselor (LAC or variation of associate counselor)

Licensed Social Worker (LSW)

Other

What state do you currently practice in? (Check all that apply) *

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

*Puerto Rico

Do you currently serve survivors of domestic trafficking and commercial sexual exploitation? *

Yes

No

What is the best form of communication to follow-up with your application? *

Phone

Email

Either