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Lifelong Wellness Center Counseling, PLLC Application
This is a W2 employee position, not an independent contractor (1099).
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* Indicates required question
Email
*
Your email
Visit
www.lwccounseling.com
for more information. Thank you!
Full Name
*
Your answer
Phone Number
*
Your answer
Home Address
*
Your answer
NPI Number (or type "N/A")
*
Your answer
Credentials and License Number(s) - MUST BE LICENSED IN CT (i.e., LPCA 12345)
*
Your answer
For Associate Clinicians, how many hours remain for your full licensure in CT?
100+ hours
500+ hours
1000+ hours
Less than 100 hours
N/A
Other:
Platforms for Services Preferred
*
In-Person and Telehealth Hybrid
In-Person Only
Telehealth Only
Required
Your Email. Send CV to
info@lwccounseling.com
*
Your answer
Clientele Experience
*
Ages 0-3
Ages 4-11
Ages 12-17
Ages 18-30
Ages 30-45
Ages 45-60
Ages 60+
Couples
Groups
Families
Other:
Required
What is your preferred clientele's presenting concern and age range?
*
Your answer
Years of Clinical Mental Health Counseling Experience
*
3+
5+
8+
10+
20+
Other:
Required
Additional Certifications and Specialties
Your answer
Paneled with Insurance Carriers
*
Anthem BCBS
Medicaid (Husky)
Aetna
Cigna
Optum
United
ConnetiCare
Oxford
Medicare
Magellan
Tri-Care
Not Credentialed Currently
Other:
Required
Are you a Registered Play Therapist/Supervisor with the Association for Play Therapy?
*
No
Yes
Actively Pursuing
No, but I'm interested!
Availability
*
Daytime
Evenings
Weekends
Other:
Required
Send me a copy of my responses.
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