Request To Join – Room to Grow Counseling Offices

Name *

First

Last

Address *

Phone Number *

Email *

License Type *

(Other)

License Level *

Fully Licensed
Internet/Associate
Supervisor

Certifications and Specialties

Supervisor's Name (If Applicable)

Supervisor's Phone Number (If Applicable)

Have you ever had a complaint filed against you with the board of your governing license? *

If yes, did the complaint result in disciplinary action taken?

Are you in good standing with the governing board of your licensure (and supervisor, if under supervision)? *

How many hours per week would you ideally utilize office space to meet with clientele or other related work (i.e. case notes, etc)? *

Days Interested in utilizing Office Space *

Times of Day Interested in utilizing Office Space *

Day Use
Evening Use
Weekend Use

Other information you would like Room to Grow Counseling Offices to know about you.

I acknowledge that the information provided in this form is correct and that I may be requested to verify this information prior to obtaining membership. *

Acknowledge