57 North Hampton Therapists Application Form

57 North Hampton Therapists Application Form

Join the Jump Start Support Team
- Name of Practitioner
  
  First NameLast Name
- Name of Practice
- Practice Address
- List your professional social media profiles (include the URLs):
- Degree(s) Obtained
- Certifications & Licensure
  
  Other
- How long have you been in the field?
- How long have you been licensed?
- What types of therapies do you practice?
  
  Other
- What areas do you specialize in?
  
  Other
- How long do your sessions last?
- What are your session fees?
- Do you accept insurance?
- What types of insurance do you accept?
  
  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?
- If you answered yes, what would that rate be?
- Is therapy offered in person or virtually?
- List your hours of availability:
- Do you do home visits?
- Do you have after hour availability for crises?
- National Provider Identifier
- Counsel for Affordable Quality Healthcare Number (CAQH#)
- What's your organizations therapeutic motto? (therapeutic approach)
- What associations are you connect to?
  
  Other
- Tax Identification Number
- Please attach your W9
  
  Cancelof
- Please attach a copy of your Liability insurance
  
  Cancelof
- Compassion
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Worst, 10 is Best
- Patience
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Worst, 10 is Best
- Open-mindedness
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Worst, 10 is Best
- Strong understanding of social justice issues
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Worst, 10 is Best
- A deep understanding of how different social issues effect different demographics
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Worst, 10 is Best
- Ability to create inclusive environments for all
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Worst, 10 is Best
- Ability to establish and maintain boundaries
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Worst, 10 is Best
- Ability to look within and identify your own unmet psychological needs and desires
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Worst, 10 is Best
- Ability to adapt and change the way you respond to meet your clients' needs
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Worst, 10 is Best
- Ability to establish rapport quickly with clients and develop strong relationships
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  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.
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Worst, 10 is Best
- Ability to listen and be able clearly explain your ideas and thoughts to others.
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Worst, 10 is Best
- 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?
- List any additional products/ services that you offer supplemental to your therapy (i.e. workshops, support groups, books, etc)
- Should be Empty: