AA Network Application (ws)
This application is for enrollment in the Arizona Network of African American Behavioral Health Providers. Approved participants will be included in a direct referral system that connects community members to psychotherapists and social service workers that are best suited to address their presenting concerns. Your information will be reviewed and may be shared with potential clients seeking services. You may be eligible for reimbursement of your services based on eligible funds and services provided. Your responses will allow us to establish you as a licensed and credentialed provider, as well as to obtain the best possible assessment of the work you do and the clients best suited for your expertise. 

Your application will be complete once we have received a copy of your resume/vitae (send to office@pppassociates.com referencing azaabh), and are able to connect with two references submitted in your application. You will be contacted to confirm your availability for referrals and the process by which referrals are made. 
Sign in to Google to save your progress. Learn more
Name *
First and last name
What is your web site address
What is your professional email address? *
Phone number *
Your Gender *
Required
Your professional office address *
Your professional discipline/degree
Clear selection
Describe degree/discipline if other
How many years have you been in professional practice?  *
What is the setting of your current practice (where you would be able to receive referrals)? *
Name of your employer, if applicable. 
Are you licensed to practice in other states? If yes please list them.
Are you providing services in person or telehealth?
Clear selection
What insurance payers are you credentialed with?
List other insurance payors you accept. 
How many years have you been credentialed with third party payers? 
What is your private pay rate for a clinical therapy session/ medication management visit? 
Do you offer a sliding scale for clinical services?
How many hours of post-degree supervision have you had? (Or how many years)
Do you currently participate in regular or routine clinical supervision and/or participate in a consultation group for your clinical work?
Do you currently provide clinical supervision? If yes, for how many years
Have you participated in your own personal psychotherapy/psychoanalysis/counseling? If yes, was it helpful for you?
Please provide a statement describing your faith practice and how you integrate spirituality into your practice.
What psychotherapy interventions are you trained to provide, if applicable? (eg. DBT, EMDR, EFT)
For areas of specialty listed above, how many post degree training hours have you received in that modality? 
What treatment modalities do you provide? (Check all that apply)
What ages of client referrals do you accept?
What clinical presentations/issues would you prefer to exclude from your referrals? (eg. domestic violence; forensic involved cases; eating disorders, substance abuse, psychosis)
What presenting problems best fit your practice? *
Required
If other presenting problems best fit your practice, please describe below.
Have you ever surrendered your clinical license or had your clinical license suspended?  *
Required
Have you ever been convicted of a criminal offense? If yes, please explain.  *
How do you prefer to schedule first appointments?
Please provide a brief autobiographical description of your progression into and/or your motivation and philosophy of practice highlighting important principles practiced and insights gained. 
Are you currently accepting new patients?
Clear selection
Information is current as of this date
MM
/
DD
/
YYYY
Please provide the names and email addresses of two references with knowledge of your clinical work. We will make requests for letters or affirmations of your practice to accompany your application. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of AZ Community Behavioral Health Services Fund. Report Abuse
Google Forms