Thank you for your interest in becoming a volunteer therapist for Trauma Support Services of North Texas. Our goal is to provide quality therapeutic mental health services for victims of violent crime and trauma survivors and their families. We are committed to providing excellent training in working with trauma survivors and related topics as well as opportunities to confer with experts in the field about difficult cases.

Personal/Professional Information

*First Name:
Middle Name:
*Last Name:
*Mailing Address:
*City:
*State:
*Zip:
*Email Address:
*Gender: Female Male
*Highest Degree:
*Degree Institution:

*License Type(s):
*Do you have at least two years post-independent licensure experience?

Yes No

Professional Liability Insurance Limits

*Occurrence:
*Aggregate:

Service Location

(where you prefer to see the clients we refer)
*Address:
*City:
*State:
*Zip:
*Appointment Phone:
Cell or Crisis Phone:
*Phone:
Fax:

*Preferred Client Age Groups:

Geriatric (ages 65 or older)

Adolescent (ages 13-17)

Adult (ages 18-64)

Child (ages 6-12)

Child (ages 1-5)

Languages other than English in which you are fluent in conducting therapy
Languages:

*Appointment Availability:

Appointments—Evening: Available to see participants after 5 p.m. on weekdays

Appointments—Weekend: Available to see participants on Saturdays and/or Sundays

Appointments—Other times

*Please write a paragraph stating why you would like to volunteer with TSSNT:

*Therapist Attestation:

I hereby certify and attest that all of the information above is true and accurate, and misstatement or omission may result in denial of application with or without appeal.

Please email or fax a copy of license or wallet card, insurance verification and resume to [ email ] or (972) 296-5313. Until we have these items we will not be able to process your application. We will email you a copy of this application, and include this information in that email.