57 North Hampton Therapists Application Form
Join the Jump Start Support Team
Practical Matters
Name of Practitioner
First Name
Last Name
Name of Practice
Practice Address
List your professional social media profiles (include the URLs):
Degree(s) Obtained
Certifications & Licensure
DCC
CADC
LCADC
CCMHC
Certified EMDR Therapist
CMAT
CSAT
MAC
NCC
NCSC
MFLC
Pastoral Counselor
LCPC
LMHC
LPCC
LMHP
LICSW
CCTP
Other
How long have you been in the field?
How long have you been licensed?
What types of therapies do you practice?
Humanistic Therapy
Cognitive Behavioral Therapy
Eye Movement Desensitization and Reprocessing
Dialectical Behavior Therapy
Mentalization Based Therapy
Interpersonal Therapy
Psychodynamic Psychotherapy
REBT
Talk Therapy
Other
What areas do you specialize in?
Substance abuse
PTSD and Trauma
Marriage and Family
Childhood and Adolescents
Geriatric
Women Issues
Men Issues
Anxiety/Panic Attacks
Depression
Other
How long do your sessions last?
30 minutes
45 minutes
60 minutes
90+ minutes
What are your session fees?
Do you accept insurance?
Yes
No
What types of insurance do you accept?
Aetna/Aetna Conventry
All Kids
BlueCross & BlueShield
Humana
United Healthcare
Behavioral Health Systems
American Behavioral
Cigna
TriCare
United Health Care
Other
If you have sliding scale options, please detail them below:
Some of our programs may offer a contract rate that differs from your normal fees. If you are selected to work with 57 North Hampton are you open to working with contract rates?
Yes
No
If you answered yes, what would that rate be?
Is therapy offered in person or virtually?
In Person
Virtually
Both
List your hours of availability:
Do you do home visits?
Yes
No
Do you have after hour availability for crises?
Yes
No
National Provider Identifier
Counsel for Affordable Quality Healthcare Number (CAQH#)
What's your organizations therapeutic motto? (therapeutic approach)
What associations are you connect to?
ACA
ASCA
AMHCA
ACCA
AMCD
NAADAC
AAGC
ADEC
NACBT
AASECT
Other
Tax Identification Number
Please attach your W9
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Please attach a copy of your Liability insurance
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On a scale from 1 to 10, with 1 being the least and 10 being the most, please rate yourself in the following areas:
Compassion
Worst
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2
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9
Best
10
1 is Worst, 10 is Best
Patience
Worst
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2
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7
8
9
Best
10
1 is Worst, 10 is Best
Open-mindedness
Worst
1
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7
8
9
Best
10
1 is Worst, 10 is Best
Strong understanding of social justice issues
Worst
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9
Best
10
1 is Worst, 10 is Best
A deep understanding of how different social issues effect different demographics
Worst
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Best
10
1 is Worst, 10 is Best
Ability to create inclusive environments for all
Worst
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Best
10
1 is Worst, 10 is Best
Ability to establish and maintain boundaries
Worst
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Best
10
1 is Worst, 10 is Best
Ability to look within and identify your own unmet psychological needs and desires
Worst
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Best
10
1 is Worst, 10 is Best
Ability to adapt and change the way you respond to meet your clients' needs
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Best
10
1 is Worst, 10 is Best
Ability to establish rapport quickly with clients and develop strong relationships
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Best
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1 is Worst, 10 is Best
Ability to relate to clients with an open, nonjudgmental attitude – accepting the client for who they are and in their current situation.
Worst
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Best
10
1 is Worst, 10 is Best
Ability to listen and be able clearly explain your ideas and thoughts to others.
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Best
10
1 is Worst, 10 is Best
Let's Talk
Do you see a therapist? Why or why not?
Describe your ideal patient:
What do you consider your strengths as a therapist?
What do you consider your limitations as a therapist?
Is your therapeutic approach more directive or guiding?
57 North Hampton has a small group of therapists that we refer our audience's questions to, as well as rely on their guidance to make policy changes and modifications to our programs. If selected as a 57 North Hampton therapist, would you be interesting being a part of this group?
Yes
No
List any additional products/ services that you offer supplemental to your therapy (i.e. workshops, support groups, books, etc)
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