Licensed Behavioral Health Services Provider Interest Form: Private Practice or Solo Practitioner
Thank you for your interest in supporting those served by the Resiliency & Justice Center.  

Please use this form to let us know about your interest in continuing to connect with the center and those impacted by trauma and mass violence. Please check or complete all items that are applicable.

For those interested in being listed as a service provider, the Resiliency & Justice Center's Multi-Disciplinary Collaborative Review Team will review the information provided. Additional information may be requested for final approval and/or to proceed as a vetted provider.

For technical support or questions, please contact us at 702-455-2433 or resiliencyandjustice@lacsn.org.
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PRACTICE INFORMATION
Provider Name *
Street/P.O. *
City *
State *
Zip Code *
Country *
Required
Practice Type *
Phone *
Phone Type *
Required
 Email *
Website
Please indicate your interest in the following: *
Required
Location/Format for Services Provided *
Required
Populations Served *
Required
License Type and Number *
Service Type(s) *
Required
Please provide a brief description of your practice, philosophy and approach. Enter "N/A" if you are uploading or sending a brochure with this information.  
Please provide a brief description of your experience with those impacted by trauma and/or violence. *
By checking "Yes" below, I confirm that I maintain records in compliance with all PHI and HIPAA regulations *
Required
EXPERIENCE WITH SPECIAL POPULATIONS
Please indicate experience of providers working with the groups indicated.
Please indicate experience with groups as related to trauma and/or violence. *
Less Than 2 Years
2-5 Years
More Than 5 years
N/A
Survivors
Bereaved
First Responders
Responder Families
Other
Additional Comments (please explain "Other" if indicated)
TRAINING
Please indicate training that has been completed and practiced. *
Required
Additional Comments
CERTIFICATION OF INFORMATION AND ACKNOWLEDGEMENTS
Providers who submit a Provider Interest Form must attest that any statements made concerning qualifications are true.

It must be understood that deception or a lack of truthfulness of any type will automatically and irrevocably result in the packet being rejected from further consideration.

The answers below pertain to certification that there are no willful misrepresentations, omissions, or falsifications in the foregoing statements and answers to the questions contained in this interest form.
Name and Title of Person Submitting and Certifying Information as Accurate *
All statements and answers contained in this interest packet are true and correct to the best of my knowledge. I understand that falsifying, withholding, or failing to answer any questions completely and accurately may cause my agency to be rejected from consideration for being referred clientele of the Resiliency & Justice Center. I understand that all information available pertaining to this application will be taken into consideration and that final approval is subject to the discretion of the Collaborative Review Team. *
Required
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