Tell Us About You

First Name

Last Name

Email

State where you are licensed (you can add more later)

Select your license type:

Mental Health PractitionerClinical Social WorkerMarriage & Family TherapistPsychologist/PsyD

Where do you currently practice?

Clinic or HospitalPrivate PracticeCommunity mental health agencyOnline platforms like BetterHelpNot currently practicing

What makes you most interested in The Topaz Group

To build my own private practiceTo supplement my private practiceTo supplement my full-time jobTo supplement my part-time jobOther

How much time do you expect to spend with Topaz clients?

Up to 5 hours a week5 to 10 hours a week10 to 20 hours a weekMore than 20 hours a week

How did you first hear about The Topaz Group

Friend or colleagueSocial NetworkOther

The Topaz Together Foundation

1433 North Water Street, Suite 400
Milwaukee, Wisconsin 53202

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