Are You a Houston Relationship Therapist? -

Full Name*
Must Match Your State License/Associate License
Expressed Gender:
Birthdate and Age:*
Email Address:*
Phone number:*
Website
Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Which BEST describes you?:*
Are you currently seeing clients?:
Are you looking for a place to see clients?:*
What is your hourly rate?
If you answered YES above, how do you collect client payments?:
Please share the history of your experience as a relationship therapist as well as what your future vision and key goals.*
List any Professional Certifications or Licenses you hold (Type "None" if applicable):*
Please tell us about yourself, including your professional pursuits, other languages spoken (if proficient in counseling in that language), and your theoretical orientation:*
Please upload a current photo of yourself:*
Max. file size: 100 MB.
Please upload your current Resume or Curriculum Vita:*
Max. file size: 100 MB.
Have you ever had a complaint filed against you?*
Do you have current Professional Liability Insurance?*
Which languages do you speak fluently?
PLEASE TYPE YOUR NAME TO ATTEST THAT YOU HAVE PROVIDED ALL TRUTHFUL INFORMATION IN THIS FORM*
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