Credentialing Details

First Name *

Last Name *

Email *

Your License Details

What license do you hold?

LMHC

LICSW

LADC

Pre-LMHC

Pre- LICSW

Other License

Other License

If you hold other license, Please Fill in Details

Issue Date
Expiration/Renewal Date
License Number

License Issue Date *

License Expiration/Renewal Date *

License Number *

I have an additional License to add *

Yes

No

Additional License Details

License Name
License Number
Issue Date
Expiration/Renewal Date

Credentialing

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

Undergraduate Degree Details

University attended for Undergraduate Degree

Which Degree Earned

Graduating Major

Emphasis or Specialization

Enrolment Date

Undergraduate Degree Earned

Graduate Degree Details

University attended for Graduate Degree

Major

Graduation date

Your Emphasis or Specialization

Your Enrolment Date

Your Graduation Date

Additional Certifications

I hold Certifications for the following treatment modalities or specialties

EMDR Certification issued by

EMDR Certification Details

PTSD Certification issued by

Eating Disorders Certification issued by

Eating Disorders Certification Details

Sexual Abuse Certification issued by

Sexual Abuse Certification Details

Drugs and Alcohol Certification issued by

Drugs and Alcohol Certification Details

LGBTQ Certification issued by

LGBTQ Certification Details

Couples/Family/Marriage Counseling Certification issued by

Couples/Family/Marriage Counseling: Certification Details

Other Certification issued by

Other Certification Details

Work History

My resume has been uploaded

Yes

No

Employer

Start Date

End Date

Supervisor

Work Address

Work Phone Number

I Have Additional Work History to Add

Yes

No

Enter work history

Employer
Start Date
End Date
Supervisor
Addesss
Phone Number