Basic Information

Full Name

Email Address

Phone Number

City/Location

Professional Background

Current License Status
LPC AssociateFully LicensedGraduate Student

Years of Clinical Experience
0–11–33–55+

Are you currently seeing clients?
Full CaseloadPartialNo

Practice Goals

Primary goal in the next 6 months

Biggest current challenge

Commitment & Readiness

Level of commitment
Ready to start immediatelyNeed more informationExploring only

Financial readiness
YesNot at this timeNeed more information

Participation readiness
YesUnsure

Hours per month you can dedicate
1–23–55+

Behavioral Insight

Tell us about a time you invested in your professional growth

Program Interest

Interest
Mentorship onlyMentorship + Office Space

When would you begin seeing clients in an office?
Immediately1–3 monthsNot at this time

Final Reflection

What would success in this program look like for you?

Agreement

I understand this program requires active participation and results depend on my effort

I understand income or client growth is not guaranteed

I understand not all applicants will be accepted