BOULDER COUNSELING COOPERATIVE LICENSED THERAPIST APPLICATION FORM

Transcription

1 BOULDER COUNSELING COOPERATIVE LICENSED THERAPIST APPLICATION FORM Please complete and return the Therapist Application Form, the Therapist Partner Membership Agreement, along with a copy of your current malpractice insurance to: Boulder Counseling Cooperative (BCC) PO Box 772 Boulder, CO Name: Degree: Gender (circle): M F Field: Type of License: License Number: Address: Office Address: Years in Practice (Post-licensure): Additional Certifications (CAC, etc.): Professional Memberships: Telephone Number: Fax Number: Optional Personal Data: Relationship Status (circle): Single Married Partnered Divorced Widowed Number of Children (include age/gender): Religion: Race/Ethnicity:

2 Therapist Application Form-Page 2 It is important to know your areas of expertise and current practice in order to direct referrals to you. In the clinical service categories below, please check all that apply: Clients: ( ) Young Children (preschool) ( ) Older Adolescents (college-age) ( ) Children (elementary) ( ) Adults ( ) Adolescents (middle & high) ( ) Seniors Treatment Issues: ( ) Adjustment ( ) Adoption ( ) Anger Management ( ) Anxiety ( ) Attachment ( ) ADHD ( ) Bipolar Disorder ( ) Cultural Issues ( ) Depression ( ) Divorce ( ) Domestic Violence ( ) Eating Disorders ( ) Explosive Disorders ( ) Gay/Lesbian Issues ( ) Grief/Loss ( ) Men s Issues ( ) OCD ( ) Oppositional Defiant ( ) Panic Disorder ( ) Parenting ( ) Personal Growth ( ) Personality Disorders ( ) Phobias ( ) Physical Abuse ( ) Physical Illness/Injury ( ) PTSD ( ) Psychosis ( ) School Issues ( ) Seniors/Aging ( ) Sexual Abuse ( ) Step/Blended Family ( ) Stress Management ( ) Substance Dependency ( ) Transitional Issues ( ) Women s Issues ( ) Other(s): Treatments: ( )Acceptance Commitment Therapy ( ) Art Therapy ( ) Behavior Modification ( ) Brief/Focused ( ) Christian Counseling ( ) Cognitive-Behavioral ( ) CouplesCounseling ( ) DBT ( ) EMDR/Brain Spotting ( ) Emotional Freedom Technique ( ) Family Counseling ( ) Family Systems ( ) Gestalt ( ) Humanistic ( ) Hypnosis ( ) Individual Therapy ( ) Jungian ( ) Meditation ( ) Mentoring ( )Mindfulness Based Therapy ( ) Parent Coaching ( ) Parenting Classes ( ) Play Therapy ( ) PSYCH-K ( ) Psychoanalytic ( ) Psychodynamic ( ) Psychological Testing ( ) Sand tray ( ) Somatic Experiencing ( ) Spanish Speaking ( ) Trauma Resolution ( ) Wilderness ( ) Other(s):

3 Therapist Application Form-Page 3 Boulder Counseling Cooperative, Inc. PO Box 772 Boulder, CO Malpractice Insurance Release Form To whom it may concern, I,, give my permission to (Therapist s Name), (Name of Insurance Company) to release information regarding my current professional malpractice insurance to the Boulder Counseling Cooperative at the above address. Signature Date

4 BOULDER COUNSELING COOPERATIVE, INC Therapist Partner Membership Agreement This Agreement will be in effect for one year, by and between Boulder Counseling Cooperative (BCC) PO Box 772, Boulder Colorado 80306, and, with a mailing address of, In this Agreement, the party who is providing Boulder Counseling Cooperative membership shall be referred to as BCC, and the party who will be receiving cooperative membership shall be referred to as "Therapist Partner". The Therapist Partner is a licensed psychotherapist in good standing in the State of Colorado, who has and maintains current professional malpractice insurance, and desires to be a member of Boulder Counseling Cooperative. BCC is willing to provide membership to the Therapist Partner. Therefore, the parties agree as follows: 1. DESCRIPTION OF SERVICES. BCC will list the Therapist Partner in the membership directory and on the BCC web site. For BCC Client Members who contact BCC by other means (e.g. phone, mail, ), BCC will provide Therapist Partner s background and contact information where appropriate. 2. PERFORMANCE OF SERVICES. BCC agrees to provide the Therapist Partner with their own web page on the BCC web site, opportunity to opt-out when they are carrying their maximum BCC client load, information regarding Client Members eligibility and session fee based on their annual income (see Addendum 1 BCC Client Fee Scale ). The Therapist Partner agrees to accept a minimum of two BCC Client Members at any one time. The Therapist Partner has the right to refuse a Client Member referral if they determine that it is not a good match. The Therapist Partner agrees to indemnify Boulder Counseling Cooperative/BCC, its directors and officers, and hold them harmless, from any and all claims, suits, damages, costs and other obligations resulting from the acts or omissions of the Therapist Partner.

5 BCC Membership Agreement Therapist Partner (Page Two) 3. TERM/TERMINATION. The term of this agreement is twelve months. Any party to this agreement may elect to terminate this agreement at any time, with or without cause, by giving sixty (60) days prior written notice to the other party. Such termination shall have no effect upon the rights or obligations of the parties arising out of any transactions occurring prior to the effective date of such termination. 4. ENTIRE AGREEMENT. This Agreement contains the entire agreement of the parties and there are no other promises or conditions in any other agreement whether oral or written. This Agreement supersedes any prior written or oral agreements between the parties. 5. AMENDMENT. This Agreement may be modified or amended if the amendment is made in writing and is signed by both parties. 6. WAIVER OF CONTRACTUAL RIGHT. The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver or limitation of that party's right to subsequently enforce and compel strict compliance with every provision of this Agreement. 7. APPLICABLE LAW. The laws of the State of Colorado shall govern this Agreement. Party receiving services: Therapist Partner s Name: By: Therapist Partner s signature Date Party providing services: Boulder Counseling Cooperative, Inc. By: Jan Hittelman, Ph.D., Executive Director Date

6 Boulder Counseling Cooperative PO Box 772 Boulder, CO ADDENDUM 1 BCC Client Fee Schedule Total Annual Individual Income Total Annual Family Income Annual Membership Fee Counseling Session Fee $35,000 - $40,000 $45,000 - $50,000 $125 $35 $30, $34,999 $40, $44,999 $100 $30 $25, $29,999 $35, $39,999 $75 $25 Below $25,000 Below $35,000 $50 $20