DGS Crisis Clinician Bio Submission Form for Website Directory

Your Name
Example: PMHNP-BC
Example: (Separate with a coma): English, Spanish, German, French
Primary County You Provide Service for DGS
Areas of Specialization
Check all that apply
Treatment Modalities Used
Check all that apply
Client Populations Served
Check all that apply
DGS Program Areas of Focus
Check all that apply
Example:
Master of Science in Nursing (MSN) – Walden University
Specialty Boards: Psychiatric-Mental Health Nurse Practitioner – American Nurses Credentialing Center
Example:
Please provide 3–4 sentences describing your professional experience at DGS, the populations you work with, and your overall approach to treatment and client care.
Example:
Please provide 3–4 sentences sharing personal interests, hobbies, passions, how you spend your free time, or fun facts that help clients and families get to know you outside of your professional role.
Example:
Please provide 1–2 sentences sharing something you really enjoy about your work with DGS.

Photo / Video Permissions

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.
Please provide a high-resolution, chest-up, color photo with a sharp focus on the eyes and a neutral, uncluttered background.
If you do not have a photo for your bio, and prefer to display the DGS logo instead, select yes below.
Please select one:
I hereby grant DELAWARE GUIDANCE SERVICES, its directors, officers, employees, agents, and designees non-revocable permission to capture/use I grant Delaware Guidance Services permission to use my name, image, and information submitted in this form in photographs, video, recordings, or other media. I understand that these materials may be used for business purposes, including on websites, social media, publications, advertisements, and other marketing or communications. I acknowledge that Delaware Guidance Services may edit or modify these materials as needed and that I will not receive compensation for their use. I waive the right to review or approve the final use of these materials and release Delaware Guidance Services from any liability related to their use. I confirm that I am at least 18 years old and have the authority to provide this consent.

 

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