Mental Health Professional Profile

Name

Email address

Primary phone

Secondary phone

WhatsApp or Other contact

Physical Address

Mailing Address

Professional Degree

Current Professional License(s) and State(s)

Liability Insurer

Current Employment

Areas of clinical expertise and interest

List any training applicable to mental health assessments.

List experience with assessment in general or with clients in the immigration process.

Languages in which you can conduct assessment

Also note any experience with interpreters

Are you available for assessments that are: Choose one or both.

Volunteer

Stipend available

Which populations can you serve: Choose all that apply.

Children

Adolescents

Adults

Seniors

Couples

Families

Technical writing requirements

Mental health documentation for immigration petitions requires extensive, precise writing. Please describe your experience with technical writing.

Technical writing sample If available, please provide a technical writing sample that demonstrates your writing ability. This does not need to be a mental health assessment and should not include confidential information.

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What would you like us to know about your availability?

What would you like to add about your motivation to do this work?

Please use this space for any additional comments you like.

I affirm that the above is accurate to the best of my knowledge. I understand that clients I serve through H.O.M.E. are also clients of H.O.M.E. as a mental health agency, with responsibility shared between myself as the evaluator and H.O.M.E. as the agency of clinical oversight. If I accept a referral from home, I will provide the client with compassionate, ethical services. I will explain appropriate consent processes to the client, consult with H.O.M.E. clinical leadership as needed, and provide H.O.M.E. with clinical records related to my services. I also agree to practice within the boundaries of my licensure and expertise. I will protect confidential information as required by HIPAA and ethical mental health practices. If for any reason I cannot complete an assessment as agreed, I will notify H.O.M.E. as soon as possible so other arrangements can be made.

Yes No

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