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Provider Profile Questionnaire

Please fill out the following form with updated, accurate information to be posted on your provider profile.

All applicable fields below must be completed. Information entered must be related to the behavioral health or healthcare fields. Degrees, licenses, and certificates in other fields should not be included by providers (eg, Masters in Business Administration).

Name*
Primary Department*
Secondary Department(s)
Location(s)*
For outpatient providers select all locations where you see patients. For community-based providers, select community-based.
LMFT, LPCC, etc.
ATR, RPT, EMDR Trained Clinician, EMDRIA Certified Therapist in EMDR, DBT-Linehan Board of Certification, Certified Clinician, etc.
Hidden
Enter 4-digit year.
In the behavioral health/psychiatric/SUD field(s)
This field is for validation purposes and should be left unchanged.
Please press “submit”  once all applicable fields are entered, and wait for the confirmation page to appear. Note, this may take up to 1 minute for confirmation. Please don’t submit multiple times.  Each provider must submit only one form.
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