Lifegiver Clinician Directory Application
Please fill out the following information FULLY. All 12 questions must have appropriate answers to be included in the directory.
Name (first and last)
At this time, you MUST have at least an associate license. Please list active license numbers (and states):
Please fill out the following questions. Incomplete answers will not be accepted.
1. Full Name:
2. Practice address (if brick and mortar):
3. If tele-health, for which state:
4. Choose at least one of the following: (Military, Veteran or FR Spouse, Military, Veteran, First Responder, Chaplain (military or FR), Retired FR)
5. What kind of mental health provider are you (LPC, LCSW, Pastoral Counselor, Addictions, etc)?
6. Any additional credentials:
7. Currently under supervision?
8. Insurance or private pay (please list insurance companies)?
9. 1-2 sentences describing your practice
10. Website URL
11. Contact information for clients to reach you:
Headshot: Please keep my work down to a minimum! Profiles are not complete until you have submitted a headshot. The following question ensures your headshot is coming my way.
I have a headshot I will now send to
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