Telemental Health Provider List
Please answer the following questions to be added to our Telemental Health Provider List
Name *
Upload Picture *
Phone Number *
Email Address *
Address / Primary Location or Region *
License Number *
(Please include all states you are licensed in)
Please Upload Proof of Telemental Health Certification *
Must include 12-18 hrs of telemental health training and Law & Ethics component. Considerations will be made for varying state requirements.
Please list the State(s) where yo are certified to provide telemental health care
Years in Practice *
Service Delivery *
Average Cost Per Session *
(include sliding scale if offered)
Insurance Accepted? *
Types of Insurance Accepted
Accepted Payment Methods *
Availability *
(include days/times with time zone)
Treatment Approach *
(include different therapies used)
Modalities *
(children, couples, group, individuals, etc)
Specialties *
(include issues of focus i.e. gender identity issues, sexual assault, race-based trauma etc.)
Theories that Inform Your Approach: *
Focal Age Group/s *
Do you have experience working with military personnel? *
Please state your experience working with Trans, lesbian, gay, bisexual, queer and non gender conforming clients? *
Please separately identify experiences with each community.
Please state your experience working with trans clients. *
About/Profile *
(please give a brief introduction of yourself and your practice in 250 words or less)
Resume *
(please attach the most recent copy of your resume)
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