First Responder Mental Health Practitioner
Profile Questionnaire
1. Name:
2. Address:
3. Home Phone:
4. Cell Phone:
5. Email Address:
6. Professional Licensure
(circle one)
LCSW
LCPC
LCC
LMFT
Other:
7. License No.:
8. License Issue Date:
9. Years in Practice:
10. Practice Insurance?:
Yes | No
11. Will your practice insurance cover work with
immigrant and refugee referrals? (circle one)
Yes | No
12. Languages spoken fluently other than
English:
13. Days available:
14. Times
available:
15. Please
describe any
relevant
experience:
16. Areas of
M
T
W
Th
F
8 – 10 a.m.
11-1 p.m.
2-4 p.m.
5-7 p.m.
8-10 p.m.
Sa
Su
Expertise (CBT,
NET, refugees,
Undocumented
students, etc.)
17. Experience
with mental
health evaluations
for asylumapplicants ?
Yes | No
18. If yes, describe:
19. Testimony
experience for
asylum cases?
Yes | No
20. If yes, describe:
21. Available transportation to
meet with families?
Yes | No
22. Additional Services: Would you be willing to provide mental health counseling to individuals
who are undocumented or families with mixed status?
22. Add me to the following
listserv?
(circle all that apply)
Yes | No
a. Illinois Refugee Mental Health Coalition (ILRMH) – www.ilrmh.org
b. Mental Health Coalition for Undocumented Immigrants (MHCUI)
Submit all materials to:
Aimee Hilado, Ph.D., LCSW
CWY Mental Health First Responder Workgroup
[email protected]
Please Note: Selected providers will need to complete trainings on Best Practices with Immigrants and
Refugees prior to receiving referrals.