Mental Health Application

  • I want more information
Last Name: First Name:
Middle Name:   
Preferred Name:   
City: State:
Zip: Cell/Home Phone:
Work Phone : Email :
Mailing Address:   
Name : Relationship :
Phone Numbers:    
T-Shirt size Adult:  S   M   L   XL   XXL
Other Previous Legal Names: Date of Birth:
(Month/Day/Year)
Driver's License and State:   
Have you ever plead guilty to OR been convicted of any criminal offense, other than minor traffic citations Yes    No
If yes, provide information on criminal offense, date, location (city and state) and disposition.
 I authorize Camp Agape to conduct a background check.
Name: Date:
(Month/Day/Year)
College/University




 Graduation Date




 Degree




 Hours Completed
(interns only)
License/Certification



 State



 License Number
Do you carry professional liability insurance? 
Graduate Student Interns
If you are not a licensed mental health provider, please describe your internship practice experiences:
Current Supervisor: Phone:
Email:   
Camp Agape estimates that there would be 36 hours of direct contact, with 4 hours of training.
Please provide any forms you will need for documentation of your participation in camp.
Please describe the training and experience you have with grief issues.
Please describe your experience in working with children and youth.
Camp Agape is a Christian bereavement camp.
Please describe your spiritual beliefs and how that impacts your life and practice.
 
  
 
  
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