Counselor

First Name

Last Name

Name of Practice

Phone

Fax

Email

Website

Practice Address

City

State

ZIP Code

Do you have a Different Mailing Address?

YesNo

Mailing Address

Mailing City

Mailing State

Mailing ZIP Code

Licensing

License

License State

License Number

Initial Date of License

License Expiration Date

Do you have more than one License?

YesNo

2nd License

2nd License State

2nd License Number

Initial Date of 2nd License

2nd License Expiration Date

Do you have more than two Licenses?

YesNo

You will be able to submit more licenses further in the process.

Specializations

Specialties/Preferences

To choose more than one hold 'CTRL' with a Windows computer or 'command' with a Mac.

Languages other than English

To choose more than one hold 'CTRL' with a Windows computer or 'command' with a Mac.

Languages not Listed

Multicultural Competencies

To choose more than one hold 'CTRL' with a Windows computer or 'command' with a Mac.

Other Multicultural Competencies

Fees

Individual Set Fee

Couple Set Fee

Family Set Fee

Do you Offer Sliding Scale Fees?

YesNo

Accepted Insurance Providers

To choose more than one hold 'CTRL' with a Windows computer or 'command' with a Mac.

Other Insurance Providers Accepted

Legal

Have you been Subject to a Professional Misconduct Suit?

YesNo

We will ask for a summary of how any suits and complaints were resolved.

Have you been Subject to a License Board Complaint?

YesNo

We will ask for a summary of how any suits and complaints were resolved.

References

Reference 1

First Name

Last Name

Email

Phone

Address

City

State

ZIP Code

Reference 2

First Name

Last Name

Email

Phone

Address

City

State

ZIP Code

Reference 3

First Name

Last Name

Email

Phone

Address

City

State

ZIP Code

Faith and Beliefs

As a faith-based organization, it is important that we have some insight into your personal faith and beliefs. Please provide a statement of your faith and beliefs here.

Click Here to view our values and beliefs.

I have reviewed the Texas Baptists values and beliefs and agree that I am of a like minded faith.

Statement of Faith and Beliefs

If you prefer to send a prepared statement of beliefs please send as an email attachment to counselingservices@txb.org

Counselor Network Application

Counselor

Licensing

Specializations

Fees

Legal

References

Faith and Beliefs