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MFT Clinical Ambassador Program: Founding Cohort Application

CLUB MFT is a weekly practice for mothers, designed by perinatal psychotherapist Elizabeth Wellington, MA, LPC, PMH-C. We're inviting 10 to 15 clinicians who work with mothers to test it in our December beta, contribute small clinical tools, and recommend it where it fits. This application takes about 5 minutes to complete.
Thanks for your interest!

First name

Last name

Email

Phone

Credentials / license type

State(s) where you're licensed

Practice name and website

City

Do you offer telehealth?

A
B

Roughly what share of your caseload is mothers, from pregnancy through parenting?

A
B
C
D

Any perinatal or maternal mental health training?

What's your theoretical orientation? Check all that apply.

Tell us about your other trainings, certifications and modalities.

What other populations do you work with? Check all that apply.

Why do you want to be a Clinical Ambassador?

What small tool could you see contributing? For example a short guided practice, a worksheet or a script.

Instagram handle

How did you hear about this?

A
B
C
D
E

Have you experienced MFT yourself? Check all that apply.

I understand ambassadors receive no referral fees, will disclose their affiliation when recommending Club MFT, and that Club MFT complements therapy and never replaces it.