FLOURISH-Provider Questionnaire "*" indicates required fields Name* If you have a headshot photo you would be willing to share in our provider directory, please upload it here:Max. file size: 50 MB.What are your pronouns?* Email* Phone*Are you a solo practitioner or do you work in a group practice?* Solo Practitioner Group Practice Other Name of Practice/Organization:* Zip Code where your practice is located* ZIP Code Website Do you offer evening hours for appointments?* Yes No Would you be willing to consider evening hours for a Scholarship Foundation student?* Yes No Other Do you offer weekend hours for appointments?* Yes No Would you be willing to consider weekend hours for a Scholarship Foundation student?* Yes No Other What are your preferred methods of communication with clients/patients?* Phone calls Email Text messages Other Please check any/all that you regularly use.Communication Preferences, OTHER: Please explain:* Are you licensed in the state of Missouri?* Yes No In which state(s) do you hold a license?* Please indicate your licensure status here:* I am fully licensed. I am provisionally licensed. I am not licensed Please upload a copy of your state license:*Max. file size: 50 MB.You have indicated that you are provisionally licensed. Please provide the name and contact information for your supervisor:*Do you carry professional liability insurance?* Yes No How much liability insurance do you carry?*Please upload proof of insurance that includes date of expiration:Max. file size: 50 MB.Are you a board certified telemental health provider (or DCC)?* Yes No Have you had any telemental health training?* Yes No Which of the following licensures do you hold?* Licensed Mental Health Counselor (LMHC) Licensed Professional Counselor (LPC) Licensed Clinical Counselor (LCPC) Licensed Professional Clinical Counselor of Mental Health (LPCC) Licensed Clinical Mental Health Counselor (LCMHC) Licensed Mental Health Practitioner (LMHP) Licensed Clinical Social Worker (LCSW) Licensed Marriage and Family Therapist (LMFT) Other Please be aware that only fully or provisionally licensed practitioners may participate. Please explain what other licensures you hold:* Treatments/Therapies: Please indicate which of the following you have EXPERTISE in:* Cognitive Behavioral Therapy (CBT) Dialectical Behavior Therapy (DBT) Motivational Interviewing Psychodynamic Eye Movement Desensitization and Reprocessing (EMDR) Family Systems Therapy/Treatment Trauma-Informed Treatment Other Please explain what other treatments/therapies you have expertise in:* Treatments/Therapies: Please indicate which of the following you USE in your therapy practice:* Cognitive Behavioral Therapy (CBT) Dialectical Behavior Therapy (DBT) Motivational Interviewing Psychodynamic Eye Movement Desensitization and Reprocessing (EMDR) Family Systems Therapy/Treatment Trauma-Informed Treatment Other Please explain what other treatments/therapies you use in your therapy practice:* Please tell us about how you settled on the treatment(s) you use in practice:*Have you had an ethics training in the past year?* Yes No When was your most recent training?* What services do you provide?* Individual Counseling Group Counseling Family Counseling Other Please explain what other services you provide:* Please list any languages in which you are fluent:* Do you offer a sliding fee scale?* Yes No Do you accept insurance?* Yes No Please list insurance that you accept:*Do you accept Medicaid/Medicare?* Yes No The Scholarship Foundation intends to cover the cost, at a negotiated or mutually agreeable rate, of therapy for students we refer as long as funds are available. How many students from The Scholarship Foundation would you be able/willing to work with?*Please tell us about yourself, including demographics (race, gender), educational background and training, as well as any considerations that are important to you and your practice:*Please share demographic information about the population(s) you serve:*What types of communities/populations do you have experience providing mental health care for?* College students Black, brown, Indigenous, Asian, and/or Latinx people Immigrants/refugees LGBTQIA+/Queer/Trans People Individuals with disability(ies) or chronic health conditions The students of The Scholarship Foundation of St. Louis are all low income and most come from families in which there are significant economic stressors. 43% identify as Black, 35% as white, 9% as Hispanic/Latino, 5% as multiracial, and 3% as Asian. An increasing proportion of our students identify as LGBTQ and do not subscribe to the gender binary. What equips you to work with these students?*Why do you want to work with The Scholarship Foundation’s FLOURISH program?*PhoneThis field is for validation purposes and should be left unchanged.
