Prospective Therapist Questionnaire Full Name Phone Email Credentials-State License Type, Certifications Up-to-Date Resume with 3 References Are there any complaints against your license? No Yes If yes, please explain Have you ever been convicted of a misdemeanor or felony? No Yes If yes, please explain Desired Sessions Per Week? 8-12 13-16 17-24 25-28 29+ Where would you like to perform therapy (check all that apply) Saginaw Bay City Flint Online What age group(s) would you like to work with? Infant/Toddler Child Adolescent Young Adult Middle-Age Adult Senior Citizen What type of presenting issues would you like to work with? Depression/Anxiety Trauma Family Couple/Relationship Child/Adolescent Behavior Medical Adjustment Substance Abuse Adult Behavior- Gambling, Shopping, Eating, etc. Sexual LGBTQ+ Personality Disorders Psychosis Other (Explain below) If other, please explain Please provide a sample progress note- redact any name or identifying information if using an actual progress note from your past. Signature (Please type full name) Date Send
