Acknowledgment and Consent for Participating Psychotherapists
Thank you for considering participation in our Access for All Community Response Program.  In these unprecedented times, we appreciate your willingness to donate your valuable service.
Participating clinicians must read and agree to the program guidelines listed below.  Once this certification form is submitted by the clinician and reviewed by The Wingspan Project, contact information for participating clinicians will be posted on the Access For All Community Response page. 
I have read and hereby certify the following:
  1. I am a clinically licensed mental health professional in the state of Illinois or I am being supervised by a clinically licensed mental health professional
  2. I have at least 5 years of postgraduate experience providing psychotherapy or I am being supervised by a clinically licensed professional who has at least 5 years of postgraduate experience providing psychotherapy
  3. I have malpractice insurance coverage (copy of declarations page provided to The Wingspan Project).
  4. I have no pending ethical or legal complaints against me.

I also agree to provide at least one hour of pro-bono psychotherapy services per week for a minimum 10 week period to a person who engages me through The Wingspan Project’s Access for All Community Response Program. In that capacity, I will give priority to one or both of the following:
  • Individuals from communities of color, in particular, those historically impacted by racial injustice, police violence and brutality, recent protests, and those who have been arrested as a result of protesting
  • Individuals whose financial circumstances have been further compromised as a result of COVID-19. As of August 2020, that includes, but is not limited to, people in the hospitality, restaurant/food service, retail, and other service industries who have been furloughed or lost their jobs as a consequence of the critically important physical distancing and stay-at-home guidelines in place throughout the Chicagoland area and the State of Illinois.

​I understand that as a participating clinician I have no legal affiliation with The Wingspan Project (“TWP”) and am not covered by TWP liability and/or malpractice insurance.