Name:
*
First Name
Last Name
Email:
*
Confirmation Email:
*
Phone Number:
Country
(###)
###
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Practice Website:
*
Therapist Type:
*
Type of License:
*
Years in Practice:
*
States licensed in:
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Fully licensed?
*
Supervisor?
*
Undergraduate Institution:
*
Post graduate Institution:
*
Specialties:
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Treatment Orientations:
*
PERSONAL STATEMENT
*
The personal statement is a way to warmly greet prospective clients and give them a sense of the benefits of therapy with you. We recommend that you write directly to your ideal client and avoid the use of jargon they might not understand.
If you are a student intern, please provide your supervisor's name and site location below.
Availability for Mindful Warrior Clients:
*
Accepted Payment Methods
*
Please note that all Mindful Warrior Alliance clients are all self-pay and will not use insurance as a form of payment. Please do not enter any insurance carriers with whom you are affiliated.
Agreement:
*
By submitting this form:
Mindful Warrior Therapist Agreement:
*
Thank you for joining Mindful Warrior Alliance! We will send you an email when you have been matched with a client, so make sure to check your spam folder! We are so excited to have you be a part of our network of mental health providers committed to supporting our military and infertility community.
