Therapist Onboarding

Employment Type

Part Time Employee

Full Time Employee

Part Time Contractor building caseload for Full Time

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

Annual Salary you agreed to:

We use this to Double Check that your contracted salary has been properly entered into payroll and adjusted for any employment benefits you may have declined

Will you be taking Leek Therapy's health insurance: *

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

Yes, but I would like to sign up for a family plan. LT will cover the cost of my individual plan, and will pay the balance of the premium as a payroll withholding.

No, I will stay on my existing plan and receive 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

I'm not currently interested in additional insurance.

Personal Information

Legal Name *

First
Middle
Last

Preferred Name/Listing Name

Social Security Number *

Personal Phone Number *

Mailing Address

Address
City
State
Zip Code
County
Country

Is your Mailing Address the same as Home Address *

Yes

Home Address *

Address
City
State
Zip Code
County
Country

Work/Client Facing Cell (if you have one)

Google Voice

I use a Google Voice phone number

I use a Google Voice phone number but it is not client facing

I do not use a Google Voice phone number

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: *

Education Background

Undergraduate School

Undergraduate Degree

Area of Study/Course of Study/Major

Graduate Degree School

Graduate Degree Earned

Graduate Degree Start Date

Graduate Degree Graduation Date

Upload a picture of your Graduate Degree diploma:

Additional certifications or specialties:

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 you've held license:
Issue Date:
Expiration Date:

For use in marketing/website/therapist bio:

Briefly summarize your work as a mental health professional:

Your area of expertise or preferred clinical focus

Please describe your therapeutic approach:

Please upload a picture/headshot (the size and background will be adjusted to match the uniformity of the other Leek Therapy headshots) *

Please submit a picture (minimum 600 kb)

Insurance Credentialing

The information provided below will be used to begin the insurance credentialing process on your behalf. If you have any questions, or do not have of the information requested, please leave those sections blank and contact the Practice Manager once you've completed as much as you can.

If you do not have an NPI, create one HERE

NPI Number (National Provider Identification). *

Required if we are handling your insurance credentialing, you can reset your password once we've completed your paperwork.

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

Number of years you've held your License *

Recertification Date *

Psychology Today Profile

Required if we are handling your insurance credentialing, you can reset your password once we've completed your paperwork.

Psychology Today Profile User Name:

Psychology Today Password:

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.