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Personal Information
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License
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License Details
Haven Haus Clinician Interest Form
Kindly complete the form in its entirety if you are a clinician seeking to join the Haven Haus group. Once complete, our team will reach out via email within 3-5 business days regarding your interest form and next steps. If you do not receive a response, please check your Spam or Junk mailbox prior to reaching out. If you still have questions, contact admin@blkhaven.com
Name
*
First
Last
Email
*
Phone
*
This number is for Haven Haus to contact you and will NOT be shown to the public.
Location
*
City
State / Province / Region
ZIP / Postal Code
How did you learn about Haven Haus?
Haven Haus Website
Facebook
Google
Indeed
Instagram
Referral (Friend/Colleague)
YouTube
Which best describes you?
*
I am a licensed Therapist / Counselor / Mental Health Provider
I am pre-licensed / under supervision
How many clinical supervision hours do you currently have?
*
If this does not apply to your situation, enter N/A.
License Upload
License Number
State/Province
State / Province
AL – Alabama
AK – Alaska
AZ – Arizona
AR – Arkansas
CA – California
CO – Colorado
CT – Connecticut
DE – Delaware
FL – Florida
GA – Georgia
HI – Hawaii
ID – Idaho
IL – Illinois
IN – Indiana
IA – Iowa
KS – Kansas
KY – Kentucky
LA – Louisiana
ME – Maine
MD – Maryland
MA – Massachusetts
MI – Michigan
MN – Minnesota
MS – Mississippi
MO – Missouri
MT – Montana
NE – Nebraska
NV – Nevada
NH – New Hampshire
NJ – New Jersey
NM – New Mexico
NY – New York
NC – North Carolina
ND – North Dakota
OH – Ohio
OK – Oklahoma
OR – Oregon
PA – Pennsylvania
RI – Rhode Island
SC – South Carolina
SD – South Dakota
TN – Tennessee
TX – Texas
UT – Utah
VT – Vermont
VA – Virginia
WA – Washington
WV – West Virginia
WI – Wisconsin
WY – Wyoming
DC – District of Columbia
Month of Expiration
Month of Expiration
January
February
March
April
May
June
July
August
September
October
November
December
Year of Expiration
Year of Expiration
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
Other
Which of the following services do you offer? Select all that apply.
In-person
Phone
Virtual
Add Another License
Remove License
If pre-licensed / under supervision…
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Within 1 month (30 days)
Within 3 months (90 days)
Within 6 months (120 days)
Within 1 year (365 days)
I am looking for supervision.
Other
Not Applicable
I am expecting my license / to complete supervision…
Practice
What’s Your Style?
Select specialties that you treat (Select up to 5 specialties that you treat)
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Adoption & Foster Care
Behavioral, Disruptive, Impulse Control Disorders
Cross-Cultural Competency
Depressive, Anxiety, & Related Disorders
Eating Disorders
Gender Identity and LGBTQIA+
Maternal Mental Health / Prenatal & Postpartum
Neurodevelopmental Disorders
Neurofeedback
Obsessive-Compulsive & Related Disorders
Personality Disorders
Psychological Testing
Relationships & Life Transitions
Schizophrenia Spectrum Disorders
Sexual Dysfunction & Related Disorders
Sleep-wake Disorders
Somatic Symptom Disorders
Substance-Related & Other Addictive Disorders
Trauma & Stressor Related Disorders
What do you treat? (Select all that apply)
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Individuals
Couples
Adolescents (Age 10 & Older)
Children (Under Age 10)
Families
Select your treatment orientation (Select all that apply)
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Applied Behavioral Analysis
Art Therapy
Attachment-Focused Therapy
Cognitive Behavioral (CBT)
CPT
DBT
Drama Therapy
EDMR
Exposure & Reponse Prevention (ERP)
Internal Family Systems
Medication Management
Mindfulness-Based
Narrative Therapy
Play Therapy
Psychodynamic
Somatic Psychotherapy
Other
Select your treatment orientation (Select all that apply)
*
How would you describe the flow of interaction during one of your typical sessions? (Select all that apply)
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The client does most of the talking & my role is to be an active / nonjudgemental listener
I often jump in and challenge the client when appropriate
I actively teach new skills / tools to the client
My style is more of a coach / motivator
I integrate art / movement in sessions
Other
How would you describe the flow of interaction during one of your typical sessions? (Select all that apply)
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When are you able to see clients? (Select all that apply)
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Before 9AM
Daytime Hours
After 5PM
Weekends
I am currently accepting new clients.
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Yes
No
If you are In-Network with insurance provider(s), which below is accurate? (Select one option)
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N/A – I am not in-network with any insurance provider(s)
I am in-network and I am open to taking new in-network clients
I am in-network but I am not open to taking new in-network clietns
Clinician Details
Tell Us About You!
What is your gender?
*
What is your gender?
Decline to answer
Female
Male
Non-binary
I speak the following languages, other than English. (Select all that apply)
*
N/A
Arabic
Amharic
Cambodian
Cantonese
Farsi
French
German
Haitan Creole / French Creole
Italian
Mandarin
Oromo
Portuguese
Somali
Spanish
Swahili
Yoruba
Other
I speak the following languages, other than English. (Select all that apply)
*
I identify as a therapist from the following background. (Select all that apply)
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American Indian or Alaska Native
Asian
Black or African American ( I do not identify as Hispanic or Latino)
Black Hispanic ( I identify as both Hispanic or Latino and Black)
Native Hawaiian or Other Pacific Islander
Other
Post-Nominal Titles (We highlight all relevant post-nominal titles on your Haven Haus profile. Kindly select all that apply)
*
AMFCT
APCC
Associate MFT
BCBA
CADC
Counselor
DMFT
LADC
LCAT
LCMHC
LCPC
LCSW
LCSW-R
LICSW
LLPC
LMFT
LMFTA
LMHC
LMHCA
LMSW
LP
LP – Associate
LPC
LPC – Associate
LPCC
LPsyA
LSW
MD
MFC
MFT-I
MHC-LP
MSW Intern
NP – Psychiatry
PMHNP
PhD
PsyD
Psychological Assistant
SLP
SP
Other
Post-Nominal Titles (We highlight all relevant post-nominal titles on your Haven Haus profile. Kindly select all that apply)
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I am interested in providing supervision to Associates.
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I'm interested in providing supervision to associates.
Yes
No
N/A – I am a nurse practitioner
N/A – I am a coach / consultant
Phone
This field is for validation purposes and should be left unchanged.
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