Therapist & Wellness Practitioner Screening Form
Thank you so much for agreeing to be one of the Pro-Bono Therapy & Wellness Providers for the DMHS Free Therapy Matching Program.

This form will be used so that once you become available to provide services, we will compare your services to what potential clients are requesting.

Please create a directory listing here before proceeding: https://dmhsus.org/find-a-bipoc-therapist-or-healer/

REQUIREMENTS: 
Accept 2 referrals for 12 sessions each per calendar year, but there is no maximum if you want to continue working with clients referred to you. 

One of the clients may be a current client, as long as they fill out the Free Therapy & Wellness Application and include your name.

OR 

You also have the option of providing 24 hours of volunteer time in a calendar year as an alternative. 

DMHS operates this program 12 months a year, with or without funding. If you agree to participate, you are agreeing to volunteer for 0 compensation if funding is not available.

DMHS Therapists & Wellness Practitioners who provide pro bono services become eligible for the following, each year that pro bono services are provided:
*First consideration for referrals 
*Featured listing in the directory 
*Opportunities for CEUs (WA State)
*Opportunities to attend free trainings by DMHS
*Opportunities to be recruited for panels, workshops and webinars
*Clinical Supervision by one of our Approved Supervisors (WA & CA)

We plan to reach out quarterly at a minimum to check on availability, but as you begin to see clients or have availability for a Pro-Bono slot, please feel free to reach out to us and request a potential client be sent to you.
Email *
First & Last Name *
Contact Phone Number *
Age Group Specialty
How many years of experience do you have in wellness or mental health services? *
Required
Are you a Wellness Practitioner or Therapist? *
Required
Are you Fully Licensed or have an Associate License (if you are a Therapist) *
Required
How many clients may we assign to you for 12 sessions each  *
Required
How do you address power differential and hierarchy (age, race, etc) in your work with clients?
What services can you connect clients with?
What racial identities do you specialize in serving? *
Required
What race do you identify as?
Where are you Located? *
Required
Are you a Licensed Therapist or Wellness Practitioner? *
Required
Do you provide teletherapy or in-person? *
What languages do you provide Therapy & Wellness Services in? *
Required
Other languages spoken
What areas of mental health do you specialize in?
DMHS is also looking for a Case Manager. Do you have Case Management experience in King County, WA?
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Other (please specify)
I understand that I am signing up to provide 12 sessions or more for up to a 12 month calendar year. I understand that I, or my future clients can terminate therapy at any point. Regardless of the circumstances, when therapy is terminated, I will provide 3 resources. If I am able to keep the client beyond 12 months, I will determine the cost of therapy with my future client. (Please type your full name below) *
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This form was created inside of DMHS: Deconstructing the Mental Health System. Report Abuse
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