Application for Initial Provider Membership Application for Initial Provider Membership The Cancer Care Collective has established membership criteria in order to ensure that individuals seeking support receive the highest standard of care from professionals who are well-versed in the complexities of psychosocial oncology. Review Membership Options Step 1 of 4 25% CompanyThis field is for validation purposes and should be left unchanged.Name(Required) First Last Phone(Required)Email(Required) Which membership option applies to you?(Required)Review Membership Criteria Criteria A Criteria B Professional License in Good Standing(Required) Yes No License Number(Required)Current OSW-C credential, or have been credentialed previously(Required) Yes No Dates of credentialing(Required)Current APHSW-C credential, or have been credentialed previously(Required) Yes No Dates of credentialing(Required) Professional License in Good Standing(Required) Yes No License Number(Required)1+ year prior experience working as a licensed clinical psychosocial care professional in an oncology, palliative care or hospice care setting.(Required) Yes No Current or prior experience facilitating a cancer or grief support group or other psychosocial intervention designed to support people impacted by cancer (MBCR course, Memory and Attention Adaptation Training, CBT-I). Must have facilitated a minimum of 8 sessions.(Required) Yes No Have consistently served people impacted by cancer in a mental health capacity (e.g., psychotherapy/counseling, whether in private practice or with a mental health agency) over time, providing a minimum of 75 clinical hours with this population.(Required) Yes No Attest to commitment to obtain at least 10 contact hours in psychosocial oncology related topics prior to your first renewal period*(Required) Yes No Completion of relevant masters or post-masters/post-doctoral coursework specifically in psychosocial oncology, trauma informed care for cancer patients, grief and loss or end of life care .(Required) Yes No Please provide details (example: Death & Dying Course, University of New England, Completed 2010, 3.0 Credits):(Required)Relevant oncology-related certification other than those listed above (Certified Grief Counselor,Advanced Certification in Thanatology, Mindfulness Based Cancer Recovery Facilitator, Certified Clinical Trauma Professional, etc).(Required) Yes No Please provide details:(Required)Current membership in Association of Oncology Social Workers (AOSW), American Psychosocial Oncology Society (APOS), Association of Pediatric Oncology Social Workers (APOSW), Social Work Hospice and Palliative Care Network (SWHPN), or active participation in your state’s psychosocial oncology networking group (if one is available).(Required) Yes No Please provide details (example, APOSW Member, 2010-present):(Required)2+ years experience working in a psychosocial oncology-related, non-clinical role such as: hospice volunteer, death doula, oncology patient navigator or advocate.(Required) Yes No 2+ years experience working in a related clinical field (oncology nursing, clinical chaplain in oncology or hospice care).(Required) Yes No Upload Resume/CV(Required)Max. file size: 50 MB. Membership Certification and Accuracy Statement(Required) I hereby certify that I fulfill the aforementioned criteria for membership in the Cancer Counseling Collective, LLC. Furthermore, I affirm that all statements and attestations provided by me are accurate and truthful to the best of my knowledge.Consent for License Status(Required) I agree to notify CCC immediately if my clinical license is revoked or expires, and understand that until my license is reinstated or renewed, my provider profile will be de-activated. I also understand that this will not result in a refund or credit for any remaining time in my current membership period.
