Free Counselor List application and declaration forms - California

LOS ANGELES SUPERIOR COURT COUNSELING REFERRAL LIST
Application

PLEASE COMPLETE ALL SECTIONS.
(Please note that any information provided on this form may be released to the public.)
Name: Business Address: Business Telephone: Do you Speak Read If yes, indicate languages: E-Mail Address: Write any language other than English fluently? Yes No

LICENSE AND EXPERIENCE
Professional License: (Attach a copy of license and current resume.) Year Obtained:

# of years experience counseling children & families: # of years counseling families involved in custody disputes: % of practice currently consisting of families involved in custody disputes:

FEES
Fee per hour: (Please attach sliding scale, if applicable.) Do you accept pro bono work? Cost for court appearance:

PROCEDURES
Do you perform psychological testing? Under what circumstances will you provide a report back to the judge who ordered the counseling?

OTHER INFORMATION
Areas of specialty: (optional) List all the continuing education courses you have taken in the last five years pertaining to custody disputes. List any course you have taken in the last five years pertaining to domestic violence. (Attach certificates.)

Signature:________________________________
Rev. 5/09

Date:________________________________

COUNSELING REFERRAL LIST FOR CHILDREN AND FAMILIES
Declaration I declare under penalty of perjury that: I have a clinical license in good standing that permits me to provide counseling services to children and/or families. (PLEASE ATTACH.) I have ATTACHED a current resume. I will notify the list administrator within two weeks of my license being revoked or suspended. I am covered by malpractice insurance and can provide proof thereof upon request. (PLEASE ATTACH.) I have a minimum of 3 years experience working with families involved in custody disputes of which at least one year is post-license. I have a minimum of 7 hours of continuing education training pertaining to families involved in child custody disputes (CERTIFICATE(S) ATTACHED). I understand that I can be removed from this list at any time upon written notice from the list administrator for any reason including but not limited to: failure to maintain my license in good standing, failure to inform the list administrator of the revocation or suspension of my license in a timely fashion, continued refusal to accept court referrals. The decision of the committee shall be final and not subject to further review. In reviewing complaints, the members of the committee are persons performing quasi-judicial functions, and presiding at quasi-judicial proceedings within the meaning of Evidence Code §703.5. The records and information in the possession of the committee regarding therapists is official information acquired in confidence by public employees in the course of their duties, and not open, or officially disclosed to the public within the meaning of both subdivisions (b)(1) and (b)(2) of Evidence Code §1040. I will not use my inclusion on this list in any advertising. ______________________________ (Signature)
(5/09)



_____________________ (Date)