Mental Health Provider Profile
"The MisEducation and Education in Mental Health" is a series of insightful discussions featuring mental health professionals and individuals with lived experiences. These critical conversations delve into diverse topics affecting us all. The forum aims to foster understanding and enlightenment about mental health in the context of relationships, family dynamics, youth, work, and beyond. These dialogues are crafted to cultivate awareness, promote acceptance, and offer coping strategies. The overarching goal is to dispel any misconceptions surrounding the influence of past and present trauma on the mental well-being of both youth and adults.
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Email *
Prefix *

Legal First Name

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Legal Last Name *
Your Profession *
License# *
Please provide a short personal statement or link to your website. *
Address *
City *
State *
Zipcode *
State(s) you are licensed in *
Where did you graduate?
What year?
If you have more than one degree, please list each and in what discipline.
(ABC University, 1985, Social Work, BSW, MSW)
Type of Therapy  *
Years in Practice *
Please add any special recognitions, awards, special certifications, or other areas of expertise here.  
Please list your specialties *
Required
Client Focused? *
Primary language *
Are you fluent in any other language? Please list each. *
Modality *
Are you currently accepting clients? *
How are you currently seeing clients? *
Required
If you have a waitlist, how long is your waitlist? *
Age *
Explain your interest in being a panelist and what unique insights or perspectives you bring to the discussion
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Specify your availability for panel discussions, taking into consideration time zones and scheduling constraints.
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Photography/Recording Consent:
Grant or deny permission for the use of any photography, audio, or video recordings during the panel discussion.
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Acknowledge your consent to use your information for panel-related purposes, such as promotion or documentation.
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I, [ Your Full Name ], hereby confirm that the information provided in this form is accurate, and I consent to participate as a mental health professional panelist in the specified event. I understand and agree to the terms outlined in this form.

(Please copy & Paste this paragrapgh in the space below and insert your full name)

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Disclaimer

By providing us with information, you acknowledge that it may be shared on our website. Visitors to our website can access your site if you provide a link. We are not liable for any misdirected traffic or errors. Ensure your website information is accurate and current. We will report any issues reported by our website visitors after due diligence.

Your information will be displayed on our website for one year and can be renewed, except in the following circumstances:
- You request its removal.
- Your license is expired, suspended, or revoked.
- Reports of unprofessional, abusive, or other misconduct are received.

Do you grant us permission to share your information on our website?
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**Photo and Recording Consent Form**

I, [Full Name], hereby grant permission to Stuck In The Middle to use my likeness, voice, and any recordings or photographs taken during the event of: "The MisEducation and Education in Mental Health" for the following purposes:

1. Publication:
   - I consent to the use of my photographs and recordings in promotional materials, including but not limited to brochures, websites, social media, and other marketing channels.

2. Archival:
   - I acknowledge that my likeness and voice may be used for archival purposes, preserving the historical record of The MisEducation and Education in Mental Health.

3. Educational Purposes:
   - I agree to the use of my image and voice for educational purposes, such as presentations, workshops, or training sessions.

4. **Media Coverage:**
   - I understand that media outlets may cover The MisEducation and Education in Mental Health, and I grant permission for the use of my image and voice in news coverage.

I understand that Stuck In The Middle will make reasonable efforts to ensure the respectful and appropriate use of my likeness, voice, and any recordings or photographs.

I reserve the right to revoke this consent in writing at any time. If I choose to revoke consent, I understand that it will apply only to future uses, and any prior uses cannot be retracted.


Participant's Full Name:
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Participant's Signature:

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Date
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