WELS/ELS Christian Therapist Network Application

1Personal

2Education

3Licences

4General

5Professional

6References

7Other

WELS/ELS members who are licensed professional therapists and have successfully completed the Acting on Hope course or have graduated with a Master of Clinical Counseling from Bethany Lutheran College, 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
Short bio*
1-2 paragraphs (1000 characters max) to be used on the website for those seeking information about you. See examples (click on any therapist)
Upload recent photo (head shot)*
Upload a small but quality photo of yourself to be used on the website.
Accepted file types: jpg, jpeg, png, webp, pdf, Max. file size: 50 MB.
Home 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 Email Confirm Email
Home phone
Cell phone
Additional phone
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
Business/clinic website
Can't finish the form? Use the Save for Later link. Enter your e-mail address on the next page and press the Send Link button.

Reference
Include one pastoral reference familiar with how you use truths from God's Word in your work.
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
Can't finish the form? Use the Save for Later link. Enter your e-mail address on the next page and press the Send Link button.

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 . . .
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 CITIZENS, RESIDENTS, TOURISTS, AND OTHER PERSONS TEMPORARILY IN THE EU:

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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Can't finish the form? Use the Save for Later link. Enter your e-mail address on the next page and press the Send Link button.

Edward Frey: [email protected] | Privacy policy
Ref: WELS/ELS Christian Therapist Network Application