Credentialing Intake

Name *

Address

Phone number

Email address *

What type of clinical services do you provide?

Please select at least one option.

Individual Therapy

Group Therapy

Family Therapy

Couples Therapy

Psychiatric Evaluation

Medication Management

Crisis Intervention

Telehealth Services

What is your area of expertise?

Please select at least one option.

Anxiety Disorders

Depression

Trauma and PTSD

Substance Abuse

Eating Disorders

Personality Disorders

Grief and Loss

Child and Adolescent Therapy

Couples Counseling

Workplace Issues

What types of payment methods do you accept?

Please select at least one option.

Insurance

Self-pay

Sliding scale

What insurance panels are you currently contracted with?

Please select at least one option.

Aetna

Blue Cross Blue Shield

Cigna

United Healthcare

Medicare

Medicaid

Humana

Kaiser Permanente

Self-Pay

What insurance panels are you interested in?

Please select at least one option.

Aetna

Blue Cross Blue Shield

Cigna

Tricare

United Healthcare

Are you interested in joining any programs?

Please select at least one option.

Medicaid

Medicare

Employee Assistance Programs (EAP)

What types of clients do you typically work with?

Please select at least one option.

Adults

Children

Families

Couples

Elderly

Have you completed any additional training or certifications?

What are your availability hours for client appointments?

What is your current licensure status?

Do you have a practice website?

What types of therapy modalities do you utilize?

Please select at least one option.

Cognitive Behavioral Therapy (CBT)

Dialectical Behavior Therapy (DBT)

Mindfulness-Based Therapy

Solution-Focused Therapy

Family Systems Therapy

Are you open to telehealth services?

What is your primary method of client intake?

Do you participate in any professional organizations?

Please select at least one option.

American Psychological Association (APA)

National Association of Social Workers (NASW)

American Counseling Association (ACA)

What is your NPI number?

What is your state license number?

What is your federal tax ID number?

What is your current practice setting?

Do you have a clinical supervision plan in place?

Any additional comments or questions?