Counselor Registry

Thank you for your interest in joining our Counselor Registry. Bridge to Care is launching the Mental Health Access Fund to support Vermont-based, MA level, prelicensed, rostered clinicians and the supervisors who guide them. Our mission is to expand affordable care for uninsured and underinsured Vermonters by strengthening the early-career counseling workforce.

Please complete the application below and submit the required supporting documents. You will receive a confirmation email once your application has been reviewed and accepted.

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Thank you for your response. ✨

Name

Phone number

Practice Name and Address

Roster or License Number

(If Pre-Licensed) Supervisor’s Name and License Number

(If Pre-licensed) Supervision Start Date and Anticipated End Date

(If Licensed) Number of Currently Active Supervisees and Their Roster Numbers

Practice Setting

Standard Session Fee

Client Populations Served

How did you hear about this opportunity?

Bridge to Care prioritizes reducing barriers for underserved Vermonters. Please describe the access gaps your clients face (e.g., cost, insurance, transportation, waitlists, stigma):

Optional: Please describe how your practice engages or supports underserved groups (BIPOC, LGBTQIA+, rural, disabled, or low-income Vermonters):

I certify that the information provided in this application is true and complete to the best of my knowledge.
I understand that participation in the Bridge to Care Fund is contingent upon verification of roster or supervision status and ongoing compliance with program guidelines.

Do you agree to these terms?

I agree

Documentation Required

Please attach or provide copies of:

Verification of rostered/license status (from Vermont Office of Professional Regulation)
Supervisor verification (for rostered clinicians) or supervisee list (for supervisors)
Current professional liability insurance certificate
W-9 form (for reimbursement)

Upload Supporting Documents Here-

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Vermont Roster or License

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Supervisor verification letter

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Professional Liability Coversheet

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