Become a Volunteer Clinician

About You

Prefix

First

Middle

Last

Suffix

Prefix: Other

Is there anything else you want us to know about how you would like to be addressed?

Contact Information

Preferred Email for PBC contact

Personal Email

Work Email

Preferred Phone for PBC contact

Mobile Phone

Business Phone for clients

Emergency Contacts

I voluntarily provide the below contact information and authorize Pro Bono Counseling and its representatives to contact the individuals below on my behalf in the event of an emergency or in the event of PBC and/or my clients are unable to reach me.

First Emergency Contact Name

First Emergency Contact Relationship

First Emergency Contact Mobile Phone

First Emergency Contact Email

First Emergency Contact Address

Second Emergency Contact Name

Second Emergency Contact Relationship

Second Emergency Contact Mobile Phone

Second Emergency Contact Email

Second Emergency Contact Address

Are you a supervised intern or do you have a graduate-level license? (LGPC, LGMFT, etc.)

Yes. I have a licensed supervisor providing my clinical supervision.No. I am fully licensed.

Supervision Information

Your Supervisor's Name

Supervision start date

Your Supervisor's Email

Supervision End Date

Supervisor's License

If a current student, which university are you attending?

Please share your current university if it wasn't listed.

I plan to volunteer by:

Accepting a pro bono client for my own caseloadProviding clinical supervision to another volunteer

Those who provide clinical supervision to licensed graduate volunteers (LGPC, LGMFT, etc.) must be Board-approved to provide supervision. If your supervisee is a licensed graduate, please check the box below to confirm the statement.

I am a Board-approved supervisor

About Your Practice

Please share the URL to your practice's website, if any.

Type of License

Liability Insurance

Click "Choose File" to upload a copy of your liability insurance. If you prefer, you may instead submit a copy of your liability insurance to us by email: yswain@probonocounseling.org, Fax 410.825.1388 or mail: Pro Bono Counseling ATTN: Yolonda Nelson-Swain 5900 Metro Drive Baltimore, MD 21215

Additional Training and Certifications

In my Office	At Another Location
Via Teletherapy	In Clients' Homes

Aetna	Blue Cross Blue Shield
CIGNA	Kaiser
Medical Assistance	Medicare
Other	Tricare
United Healthcare	Wellpoint (formerly Amerigroup)

Children	Adolescents
Adults	Couples
Families	Older Adults

Attention Deficit Hyperactivity Disorder (ADHD)	Anger Management
Anxiety	Autism
Career Counseling	Depression
Domestic Violence

Thank you for volunteering your professional services to Pro Bono Counseling (PBC).

Become a Volunteer Clinician