Supporting Mamas Provider Application
Before including a provider's information as a Local Resource on our website, we ask that each provider submit this application for consideration.
Name *
Your answer
E-mail Address *
Your answer
What is your profession? *
Please check all that apply.
Required
Practice Name
Name of hospital, clinic, practice group, organization or tell us if you are a solo or private practitioner.
Your answer
Street Address
Include unit number.
Your answer
City, State and Zip
Your answer
Phone Number *
To be included on our website.
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 postpartum mood disorders (PPMDs)? *
Your answer
Do you meet the following criteria? *
Required
Do you take insurance? *
If yes, which insurance do you accept?
Your answer
Do you take Medicaid? *
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 in treating women (and men) with pregnancy and postpartum mood disorders? *
Your answer
What trainings about pregnancy and postpartum mood disorders have you attended (in-person or on the web)?
Please include the names and dates of these trainings.
Your answer
If you prescribe medications, do you have knowledge of:
What is your clinical orientation and philosophy?
Your answer
Would you like to be included on the Supporting Mamas Local Resources and Providers page/list? *
Would you like to receive information on upcoming perinatal mood disorder trainings for birthing professionals? *
Required
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