Personal Contact Information:
Please provide a reliable address where you can receive physical mail. Ideally this is a location where you will continue to receive mail in the event that your practice location were to change.
All behavioral health providers are required to maintain liability insurance in order to bill & collect from most insurance panels. Minimum coverage amounts are $1,000,000/ per occurrence & 3,000,000 / Aggregate
Licensure & Résumé
Please upload a copy of your professional license(s) and résumé below:
Certifications & Specialties:
Please describe any certifications and/or specialties you may have below:
Board certification requirements go above and beyond state licensing requirements. The “Board Certified” title recognizes providers that acquired certification to demonstrate an expertise in a particular specialty. This certification process is voluntary and not to be confused with the examinations taken to meet the requirements needed to apply for a license to practice in your state
Select 'Yes" if any of these have ever been relinquished, denied, revoked, sanctioned, challenged, investigated, surrendered, etc.
Select 'Yes" if your liability policy has ever been cancelled, restricted, declined, had a claim submitted, etc.
Excluding any minor traffic violations, select 'Yes' if you have ever been convicted/plead guilty to a felony, misdemeanor, civil offense, etc.