Email Address

May we ask where you reside (city and state)?

License type

State(s) of licensure

License number(s)

Please describe any prior experiences (positive and/or negative) providing online therapy.

Please tell us about your experience with private practice/clinical work.

What are your long-term professional goals (3, 5, or 10 years out)?

How might your colleagues describe you?

How might your clients describe you?

Please describe your therapeutic approach.

Please list any specialties, certifications, previous experiences, or unique trainings that enhance your therapeutic skills.

How do you help clients feel comfortable during their first session?

Would you be interested in optional bi-weekly consultation groups?

Please explain why you feel that UCW would be a good fit for you.

How did you hear about us?

Therapist Questionnaire