Professional Registration Form First Name Last Name Gender Male Female Email Phone number Address Highest degree earned Institution Year of Graduation Professional identification no. When last renewed Professional License/Certification Years of Experience Areas of Expertise Individual Counseling Couples Counseling Family Counseling Group Therapy Substance Abuse Counseling Trauma Counseling Mental Health Counseling Days and Times Available for Counseling Sessions Approach and Techniques Fluency in Languages (check all that apply) English Twi Ewe Ga Dagbani Additional Information Terms and Conditions I agree to abide by the ethical guidelines and standards of practice in counseling, psychology, and therapy. I authorize the use of the information provided for the purpose of counselor registration Send
