Therapist Onboarding

Employment Type

Part Time Contractor (1099)

Full Time Employee

PT Contractor building caseload for Full Time

If you have already received and signed your formal job offer, please enter the following information. We can fill this in for you later but it ensures that you understand your compensation package.

Annual Salary you agreed to:

Will you be taking Leek Therapy's health insurance:

Yes, I will participate in the 100% covered Individual Plan

Yes, I will participate in the LT health insurance but I would like to sign up for a family plan, LT will contribute the cost of my individual plan and will pay the balance of the premium as a payroll withholding

No, I am choosing to stay on my existing plan take a $5,000 salary increase

I have not decided

I would like to add the following to my insurance package and pay for it with a payroll deduction:

Dental Insurance

Optical Insurance

I'm not presently interested in additional insurance

Resume Information *

I can upload a Resume file

I want to add Resume Information Manually

Required Resume Information

If your Resume has not been uploaded

Give Three Professional References, including phone number and email

Provide Work and Internship History here:

For use in marketing/website/therapist bio

Legal Name *

First
Middle
Last

Preferred Name/Listing Name

Home Address *

Address
City
State
Zip Code
County
Country

Is your Mailing Address same as Home Address *

Yes

Mailing Address

Address
City
State
Zip Code
County
Country

Upload Identification for Federal I-9 Form

Upload 1 of the following *

Front and Back pictures of your Driver’s License

ID page of your valid Passport

Front and Back pictures of your Driver’s License

ID page of your valid Passport

Also Upload One of the Following *

Social Security Card

Picture of a Mortgage/Lease/Utility bill with your name and address on it

Social Security Card

Picture of a Mortgage/Lease/Utility bill with your name and address on it

License/Licenses Held in MA *

Other License Details

Years of Holding
Expiration Date
Issue Date

Number of years you've held your License *

Undergraduate Degree

Undergraduate School

Graduate Degree School

Graduate Degree Start Date

Graduate Degree Graduation Date

Additional Certifications or Specialties

Please describe your therapeutic approach

Briefly summarize your work as a mental health professional

Your area of expertise or preferred clinical focus

Area of Study/Course of Study/Major

Work/Client Facing Cell (if you have one)

Please upload your picture/headshot for the website

Google Voice

I use a Google Voice phone number

I use Google Voice but it is not client facing

I do not have a Google Voice phone number

Mobile Phone Type

iPhone

Android

Please provide the information below so that we can begin the credentialing process for you. If you have questions, or don't have some of the information requested, please leave those sections blank and contact the Practice Manager once you've completed as much as you can.

Social Security Number

NPI Number (National Provider Identification). *

If you do not have an NPI, create one HERE

License Number (for LMHC and LICSW). *

If you don't have the number available, look it up HERE

Recertification Date *

Upload a picture of your Graduate Degree diploma:

CAQH User Name (required if we are handling your credentialing)

CAQH Pass Word (required if we are handling your credentialing, you can reset your password once we've finished filing your paperwork)

Psychology Today Profile User Name: (if you would like us to manage this for you)

Psychology Today Password: (if you would like us to manage this for you)

Your Banking Information:

We need your account information to set up electronic payments

Your Bank's Routing Number: (it's on the bottom left side of your checks)

Your Account Number: (it's on the bottom center of your check, to the right of your routing number and the left of the "digital" check number)

Upload a picture of a blank or voided check:

I Consent to Receive SMS Notifications, Alerts from Leek Therapy.