Application for Licensed Mental Health Professional Partnership

Please Complete all fields below:

Date*

Name*

First Last

Phone*

Email*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Preferred Contact Time*

License Type*

Please select your license type below:

Enter License Number*

Enter NPI #*

Date Issued*

Which Jurisdiction are you licensed?*

If you are licensed to practice in other states, please list license numbers and states below:

Has your license ever been suspended or revoked?*

Is your license to practice currently valid?*

Please attach your License/ Credentials

Max. file size: 100 MB.

Please attach a Government Issued ID*

Max. file size: 100 MB.