Telemental Health Provider List
Please answer the following questions to be added to our Telemental Health Provider List
Name *
Upload Picture *
Required
Phone Number *
Email Address *
Website
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.
Required
Please list the State(s) where yo are certified to provide telemental health care
Years in Practice *
Service Delivery *
Required
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: *
Required
Focal Age Group/s *
Languages
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)
Required
Thank you! Please click below to submit this form.
Submit
Never submit passwords through Google Forms.
This form was created inside of BEAM. - Terms of Service