Clinician Vetting Form

Are you a licensed clinician who provides support to First Responders and would like to be listed as a resource with Boots on the Ground?

Please complete the form below to submit your request for inclusion on our Resources page. All submissions are reviewed and approved prior to being added to ensure alignment with our mission of providing trusted support to First Responders.

Note for clinicians: Once your submission is approved, the information that will be publicly displayed on your listing on our Resources page includes your name, organization (if applicable), discipline, registration number, address (or indication of virtual services), phone number, email address, and website.

This page is intended solely for clinicians submitting a request to be listed and is not used to request clinician referrals.

Please complete this form for the initial vetting and credentialing process.

PROFESSIONAL DETAILS

Email*Full Legal Name of Clinician and Practice*Professional License Number*State/Province of Licensure*Primary Clinical Specialization* Years of Post-Licensure Clinical ExperienceHighest Degree Achieved*Have you ever had a license suspended or revoked*

YesNo

Have you been subject to any malpractice claims or disciplinary actions in the last 5 years?*

YesNo

EMPLOYMENT & EXPERIENCE DETAILS

Please provide a brief summary of your current employment/practice setting*How much experience do you have with treating first responders? How much clinical supervision and/or consultation did you have to learn about the nature of the first responder profession, stressors, and culture?*How much experience do you have with treating individuals who are experiencing the cumulative impact of operational and/or traumatic stressors?*Many first responders may have treatment funded by workers compensation: do you work with Workers Compensation (e.g., WSIB)?*Do you have experience dealing with operational stress injuries such as PTSD, depression, anxiety, substance abuse, moral injuries, compassion fatigue and vicarious trauma?*Do you practice evidence-based approaches to trauma treatment (as per the American Psychological Association’s Clinical Practice Guidelines for PTSD, or the International Society of Traumatic Stress Studies guidelines)?

(Some examples are prolonged exposure, cognitive processing therapy, EMDR, cognitive behavioural therapy incorporating exposure)*Do you use cognitive behavioral therapy (CBT) in your practice on a regular basis?*What other treatment approaches do you use?*How much experience do you have with a return-to-work process for first responders?*As part of BOTG service standards, clinicians must be able to schedule an intake appointment within 2 weeks of referral. (Sooner being optimal). Can you meet this requirement?*

YesNo

Upload CV/Resume*Note: Accepted file types include doc, docx, pdf, jpg, jpeg, png, Max. file size: 10mb

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Thank you for your submission- A member of team will contact you shortly to confirm if your Clinician Listing is approved.

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Clinician Resource Listing Request Form

Are you a licensed clinician who provides support to First Responders and would like to be listed as a resource with Boots on the Ground?

Looking for Local Clinicians or Resources?

If you are a First Responder, family member, or support person looking to view available clinicians and resources in your area, please visit our Resources page.