Acknowledgment and Consent for Participating Psychotherapists
Thank you for considering participation in our Access for All Pro Bono Psychotherapy Network. 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 Pro Bono Psychotherapy Network page.
I have read and hereby certify the following:
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 Pro Bono Psychotherapy Network. In that capacity, I will give priority the following:
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.
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 Pro Bono Psychotherapy Network page.
I have read and hereby certify the following:
- 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
- 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
- I have malpractice insurance coverage (copy of declarations page provided to The Wingspan Project).
- 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 Pro Bono Psychotherapy Network. In that capacity, I will give priority the following:
- people impacted by COVID
- BIPOC communities
- LGBTQIA+ communities
- people who are precariously housed and/or homeless
- immigrant, refugee and first generation communities
- people who are uninsured/underinsured
- older adult communities
- people struggling financially
- people previously incarcerated
- people at the intersections of these communities
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.
