Boost 200+ Intent to Apply

Thank you for your interest in applying to the Boost 200+ Program!

Boost 200+ accelerates the licensure of Master’s-level Social Workers, Counselors and Marriage and Family Therapists in Virginia by covering supervision costs. It is targeted to individuals who aspire to become licensed therapists and must pay for licensure-required supervision themselves. This includes those just starting to accrue clinic and supervision hours and individuals who have already begun supervision hours if they have completed less than 60% of the Clinical and Supervision hours required to become licensed as an LCSW, LPC or LMFT in Virginia.

This form should take you no more than 10 minutes to complete. Please note, the form will not automatically save, please be prepared to complete it all at once. VHCF will review the information you provide and will contact you, if you will be invited to apply.

For consideration, please plan to complete this Intent to Apply form before December 31, 2024.

Boost 200+ program information including Participant Guidelines and FAQs can be found at vhcf.org/Boost200.

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* 1. First Name

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* 2. Middle Initial

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* 3. Last Name

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* 4. Date of Birth

Birthday

Date

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* 5. Email Address (One you check regularly. VHCF will contact you via email regarding your Intent to Apply/Application.)

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* 6. Cell Phone Number

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* 7. Home Street Address

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* 8. City

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* 9. State

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* 10. Zip Code

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* 11. Gender Identity

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* 12. Race

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* 13. Ethnicity

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* 14. Are you a first-generation graduate? (Parent/guardian did not graduate from college)

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* 15. Will you now, or in the near future (including the 2-year service commitment period) require employer Visa sponsorship?

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* 16. Financial Information

Your Annual Salary ($)

Total Household Income($)

Current Student Loan Balance ($):

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* 17. Please indicate if you meet any of the Boost 200+ Preferred Selection criteria below. Note: Interested candidates who do not meet any priority category noted below are also encouraged to apply.

Person of Color

Fluently Bilingual (able to provide therapy in English and another language)

I work in Southwest Virginia, Southside Virginia, or another rural area of Virginia

I do not meet any of the Preferred Selection Criteria

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* 18. Name of Virginia University/College that issued your Master’s degree

I attended graduate school outside of Virginia. (Please provide the school name, city and state.)

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* 19. Please indicate below if you graduated or will graduate from a Master of Social Work (MSW), Master of Counseling (MC) or Master of Marriage and Family Therapy (MFT) Program? Note: To participate in Boost 200 you must hold an MSW , MC or MFT degree.

Master of Social Work

Master of Counseling

Master of Marriage and Family Therapy

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* 20. Graduation Date

	Month	Year
Date	Date Month menu	Date Year menu

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* 21. Have you submitted an application to the Virginia Department of Health Professions (DHP) to begin licensure-required Supervision?

Yes

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* 22. If yes, when did you submit your application?

	Month	Year
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* 23. Have you received approval from the DHP to begin Supervision?

Yes

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* 24. If yes, what date did you receive approval by the DHP to begin Supervision?

	Month	Year
Date	Date Month menu	Date Year menu

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* 25. Current Supervisor Information

Name

Email Address

Phone Number

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* 26. Additional Supervisor Information, if applicable

Name

Email Address

Phone Number

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* 27. How many supervision and clinical hours have you completed as of the date you submit this Intent to Apply?

Supervision Hours (100 total hours for social workers; 200 total hours for Counselors and Marriage and Family Therapists)

Clinical Hours (3,000 total hours for social workers; 3,400 total hours for Counselors and Marriage and Family Therapists)

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* 28. Eligible applicants must be paying for or anticipate paying for most or all of their supervision hours. Select the option below that applies to you.

I must pay for all of my Supervision hours

I must pay for most of my Supervision hours (Approximately 50% or more)

I do not pay for supervision at this time

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* 29. What hourly rate do you pay for your Supervision hours for Supervisor 1?

Individual

Group

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* 30. What hourly rate do you pay for your Supervision hours for Supervisor 2, if applicable?

Individual

Group

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* 31. What is the organization name of your primary worksite?

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* 32. What type of organization is your primary worksite?

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* 33. Location (city/county) of your primary worksite

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* 34. Estimated hours/week of licensure-required Direct Clinical hours at your primary worksite

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* 35. What is the organization name of your secondary worksite, if applicable?

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* 36. What type of organization is your secondary worksite (if applicable)?

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* 37. Location (city/county) of your secondary worksite (if applicable)

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* 38. Estimated hours/week of licensure-required Direct Clinical hours at your secondary worksite (if applicable)

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* 39. How did you hear about Boost 200+?

Email from my graduate school

Social media from my graduate school

Professional association's email

Social media post from my professional association

Friend/classmate/colleague

Handshake

Other (please specify)

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* 40. Attestation: By checking each box and clicking “Submit,” you are attesting that you have completed this Intent to Apply accurately to the best of your ability.

I understand and agree that in return for Boost 200+ paying for my supervision hours, I commit to practicing as a licensed therapist in Virginia for two years (4,000 hours).

I will complete supervision hours at the average rate of 4 hours monthly for social workers or 8 hours monthly for counselors.

I do not have an active service commitment from other scholarships or loans.

I understand that if invited to apply for Boost 200, I must submit the additional required documents including a personal statement, resume and recommendation form within 30 days of receiving that invitation.

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* 41. Please select the date you are submitting this intent to apply.

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