WELS/ELS Christian Therapist Network Application

1Personal

2Education

3Licences

4General

5Professional

6References

7Other

WELS/ELS members who are licensed professional therapists are encouraged to join the WELS/ELS Christian Therapist Network. Fill out this application for consideration. You may save the form and return to it later to complete it. Be sure to fill in all required fields. A field marked with a red asterisk is required.
Application date*
MM slash DD slash YYYY
Application status*
- Full member (licensed professionals)
- Associate member (coach, staff ministers, student in therapist training, etc.)
Personal Information
Name*
First Middle Last
Address*
Address line 1 Address line 2 City State/Province Zip/Postal code Country
E-mail*
A confirmation e-mail will be sent to the e-mail provided.
Enter e-mail Confirm e-mail
Home phone
Cell phone
Additional phone
Permanent address (if different from above)
Address line 1 Address line 2 City State/Province Zip/Postal code Country
Date of birth*
MM slash DD slash YYYY
Gender*
Marital status*
Ethnicity*
Other*
Professional Information
Self-employed*
- Yes
- No
Current employer/Business name*
Business address
Address line 1 Address line 2 City State/Province Zip/Postal code Country
Phone
Years at current employer
Capacity
Office web site
Best Means of Communication
How would you prefer the NETWORK to communicate with you in the future?*
- Personal e-mail
- Business e-mail
Personal e-mail*
Enter e-mail Confirm e-mail
Business e-mail*
Enter e-mail Confirm e-mail
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Graduate School(s)
Academic institution*
Years attended*
Address*
Address line 1 City State/Province Country
Degree information*
Highest degree attained Course of study Minor field of study
Academic institution
Years attended
Address
Address line 1 City State/Province Country
Degree information
Highest degree attained Course of study Minor field of study
Undergraduate Colleges/Universities
Academic institution*
Years attended*
Address*
Address line 1 City State/Province Country
Degree information*
Highest degree attained Course of study Minor field of study
Academic institution
Years attended
Address
Address line 1 City State/Province Country
Degree information
Highest degree attained Course of study Minor field of study
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Current Licenses/Certifications
License/Certification*
Number*
State*
Date granted*
MM slash DD slash YYYY
End date*
MM slash DD slash YYYY
License/Certification
Number
State
Date granted
MM slash DD slash YYYY
End date
MM slash DD slash YYYY
License/Certification
Number
State
Date granted
MM slash DD slash YYYY
End date
MM slash DD slash YYYY
If student or not licensed/certified, when do you expect to be licensed/certified?
What will the license be in?
Have you ever had your license/certification revoked or suspended?
If so, please identify the details and action that occurred.
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Professional Liability Insurance
Company name
Phone
Address
Street address City State
Insurance information
Policy number Limits per incident Aggregate Coverage dates
Church Affiliation
Church name*
Affiliation*
Phone*
Address*
Street address City State
Pastor(s) first and last name*
Select (+) to add a new row.
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References
Include one pastoral reference and two professional references. One professional reference must be familiar with how you use truths from God's Word in your work.
Name*
Address*
Street address City State
Phone*
Years known*
What capacity*
Name*
Address*
Street address City State
Phone*
Years known*
What capacity*
Name*
Address*
Street address City State
Phone*
Years known*
What capacity*
Permission*
I give my permission to the Membership Committee of the WELS/ELS Christian Therapist Network to contact the above references.
Date*
MM slash DD slash YYYY
Applicant signature*
Use your mouse or touch pad to add your signature.
Type name*
First Last
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Other Information
How did you learn of the Network of Therapists?
How do you hope your participation in this network of professional WELS/ELS therapists to be of benefit . . .
. . . to you as a professional therapist?
. . . to your clients?
. . . to the pastors and teachers who refer to you?
Describe three ways that you commonly integrate Christ-centered, Bible-based truths into your current counseling practice.
Would you be willing to further your education and enhance your skills (and add to your credentials) through completion of the training course entitled "Acting on Hope"?
• Learn more about Acting on Hope.
• Register for Acting on Hope class.
- Yes
- No
What other training are you interested in receiving? Please list topics, speakers, etc.
Please share information about other WELS/ELS professional therapists (licensed or not yet licensed) that would be interested in receiving information about this Network.
(Please include full name, address, phone, and e-mail, and the best way to contact them.)
Data Privacy & Permission*
I AGREE with the terms of the WELS Privacy Policy.
NOTE TO EU RESIDENTS:

By submitting this form you consent to any and all information you provide and submit via the site being sent to the United States of America. The United States has not sought nor received a finding of “adequacy” from the European Union under Article 45 of the GDPR. WELS relies on derogations for specific situations as set forth in Article 49 of the GDPR. You are also informed that the United States presently does not have an adequate level of personal data protection as determined by the European Commission’s adequacy decision on October 6, 2015 (case c-362/14) and articulated in the European Union’s General Data Protection Regulation and has not received a similar designation of adequacy by any other foreign data protection authority. You agree to the transfer of your data and personal data to the United States, however, to be used in accordance with WELS Privacy Policy.
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Edward Frey: pastorfrey@cableone.net | Privacy policy
Ref: WELS/ELS Christian Therapist Network Application