PPSM Mental Health Provider Application
This form is used for those interested in being part of the PPSM Provider Resource List. This form can be used for those who are mental health providers, or applying to be accepted at the provisional level (additional questions asked).

PPSM’s provider resource list is a list of mental health, psychiatric, and integrative providers who have advanced training in treating PMADs. Over the years, we have created a database that has reputable providers that have been vetted, so that the community can have access to the best possible care. For these reasons, we have created guidelines for providers who are eligible to be listed in this database. We are looking for Competency, Commitment and Connection in the PMADs community.

Creating these requirements has given our organization credibility that we are proud of! We hope that you will be proud to be a part of our resource list.

**Note: If you are applying as a clinic/group, an application needs to be completed for each clinician.

Email address *
Today's Date *
Name *
What is the best phone number to reach you? *
What is the best email address to reach you? *
Clinic Name
What is the address of your clinic location? *
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