New Mental Health Practitioner

"*" indicates required fields

Your Name*

First Middle Last

Your Email*

Your Phone #*

Your Date of Birth*

Your Social Security Number*

Your Gender*

Male

Female

Your HOME Address*

Street Address Address Line 2 City State ZIP Code

Your Individual NPI #*

Your Credentials (abbreviations)*

Your License #*

Your Taxonomy Code

Do you have a CAQH account set up yet?*

Yes

No

If yes, please list username and password:

Name of FIRST Professional Reference*

Please provide a professional reference of yours. This does not mean a personal friend or family member.

First Last

What is their profession?*

For example, Applied Behavioral Analyst, Chiropractor, etc.

Email*

Phone*

Address

Street Address Address Line 2 City State ZIP Code

Name of SECOND Professional Reference*

Please provide a professional reference of yours. This does not mean a personal friend or family member.

First Last

What is their profession?*

For example, Applied Behavioral Analyst, Chiropractor, etc.

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of THIRD Professional Reference*

Please provide a professional reference of yours. This does not mean a personal friend or family member.

First Last

What is their profession?*

For example, Applied Behavioral Analyst, Chiropractor, etc.

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please upload a copy of your state license AND your Curriculum Vitae/Resume*

You can upload a pdf or jpg files.

Drop files here or

Max. file size: 256 MB.

Do you have any comments?