Full Name *

Email *

Phone *

Address (Candidate Must Located in Michigan)

Professional Information (Current License/s) (Michigan license required.)

Licensed Professional Counselor (LPC)

Limited Licensed Professional Counselor (LLPC)

Master's Level Psychologist

License Number

Years of Experience in Counseling

Preferred Availability (Days/Hours)

By submitting this application, I consent to White Oak Counseling & Recovery processing my personal information for employment evaluation purposes. I understand that my information will be kept confidential.