Perinatal Support Washington
Thank you for applying to be on our provider list. In order to be listed you must meet the following requirements
* 12 CEUs in Perinatal Mental Health (5 for non mental health professionals)
* 2 years in practice
* Up to date and licensed in your field (associate licenses do not meet this requirement)
(If you are working towards these requirements, you are welcome to complete this application and we will keep your info on file.)
Name *
Your answer
Personal Information
Street Address
Billing Address, practice address will be listed separately.
Your answer
City
Your answer
Zip Code
Your answer
Phone Number
Your answer
Email Address *
All communication with PS- WA is conducted electronically.
Your answer
Are you interested in learning more about volunteer opportunities with PS- WA?
Opportunities include board membership, leading postpartum support groups, being a warm line volunteer and administrative support tasks.
What is your profession?
Check one or more.
Practice Information
Practice Name *
Name of hospital, clinic, practice group, organization or tell us if you are a solo or private practitioner.
Your answer
Street Address
( If different from billing address)
Your answer
City
Your answer
Zip Code
Your answer
Phone Number *
This number will be published as referral phone
Your answer
Email
This email will be published as referral info.
Your answer
Website
Your answer
How long have you been in practice? *
Your answer
How long have you worked with pregnant families and families with perinatal mood and anxiety disorders (PMADs)? *
Your answer
Do you have a specialty working within a specific community?
(LGBT families, families of color, language proficiency, teen parenting, etc.)
Your answer
Do you meet the following criteria? *
Required
Do you take insurance? *
If yes, which plans do you take?
Your answer
Do you take Medicaid? *
If yes, which Medicaid plans do you take?
Your answer
Have you completed two or more of the following?
Check all that apply.
What are your current professional and volunteer activities?
Your answer
What is your experience with treating parents with perinatal mood and anxiety disorders?
Your answer
What trainings about perinatal mood and anxiety disorders have you attended (in person or web-format)?
Please provide dates of training and name of trainer(s).
Your answer
If you prescribe medications, do you have knowledge of:
If you have received specialized training in medication management of pregnant and breastfeeding parents, please include training in the question above.
What is your clinical orientation and philosophy?
Your answer
Which Provider Referral List are you applying for? *
Please note: listing on our website is benefit of our professional membership program which requires a fee. You can read more about it on our membership page- http://perinatalsupport.org/for-providers/membership/
If you are applying to be listed on our website- please include a short bio and website link as you'd like to be listed on our provider list:
Sample: Licensed Clinical Psychologist in private practice with a focus on perinatal and postpartum mood and anxiety disorders, life transition to parenthood, and early childhood bonding/attachment. Provides child parent therapy for children ages 3-7. Extensive experience with children and trauma, and families involved in the foster care system. Volunteer on the Warm Line at Perinatl Support WA and teach parent education at Suchandsuch Community College.
Your answer
Requirements to remain on our provider lists:
By checking the box you agree to the following: *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service