ProVault Participation Application Form
 Thank you for requesting to participate in the ProVault Program. Please complete all questions and provide feedback that will help the provider assess if they can work with your case.  Any issues that you may have will be directed to Casey Kenny at CaseyKenny@CounselingProfessionalsPLLC.com. 

Details on the ProVault Program and process can be found here:

https://www.cpdelphi.com/provault-program

Participants are selected on best fit, so please fill out this form thoroughly to help us determine if you can work with our participating providers.

Thank you!

Emergency Disclaimer:
IF EMERGENCY: Contact 911 or your local hospital for assistance. Submitting this form is not an emergency contact point.
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Email *
Do you have a therapist gender reference? *
Can you meet in person or telehealth? *
Would you be able to commit to three sessions, preferably 1 session per week for three weeks? *
Day and Time availability Note
If filling out this form, filling in date and time may work better if you turn your phone sideways.
What days and times would you be available?
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If a ProVault time option is not available, would you want to be contacted about Discounted or Pro Bono Services? *
Have you read the ProVault Details Page (https://www.cpdelphi.com/provault-program)?
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What topic area would you be interested in counseling? *
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Do you attest that you are not a danger to self or others? *
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