Counseling Referral Interview

Volunteer - Counselor Interview

Name: *

Email: *

Phone: *

Campus:

Name: *

Email: *

Phone: *

Home Campus:

Do you consider yourself a person of faith? If so, briefly describe your spiritual beliefs and/or theological standpoint. *

To what extent do you use your faith/spirituality as a part of your practice? *

Do you have a home church? If so, how are you involved there? *

What are your views on counselors recommending divorce/separation? *

What are your views on LBGTQ+? *

What are your qualifications and educational training? Licensed? Certified? *

How long have you been in practice? *

How is your practice set-up? Do you have other staff? *

Do you have any areas of specialty? If so, what are they? *

Do you have liability insurance? *

What, if anything, do you refer out? *

What patient medical insurance do you accept? Are you willing to negotiate rates with clients who have a hard time affording therapy? *

Additional Notes

Volunteer Signature: *

First Name: *

Last Name: *

If you are human, leave this field blank.