Mental Health Clinician Provider Submission

Thank you for your interest in submitting your information for our Frontline Provider Network. This form is intended for individual mental health clinical providers to complete a profile of their professional services and experiences and to demonstrate their experience and competencies among the first responder population. Please take time to complete all the sections within this form as thoroughly as possible. Required fields are noted with an (*), but the more information you can provide through this form, the better we can get to know you. Our goal is to provide a network of agencies to collaborate with one another, exchange resources, and share clinician providers with first responders when they are seeking clincial services or guidance.

Provider Network Process:

The 100 Club of Illinois is currently collecting mental health clinical provider details to build our internal list of providers who are well trained and competent in serving the first responder population (Law Enforcement Officers, Correction Officers, Firefighters, EMTs, Dispatchers, Survivor Families). The 100 Club of Illinois will consider your services for referral based on your first responder experience and knowledge, service type, and geographical location, and stay in touch with you regarding collaboration and training opportunities.

You may be contacted for further questions, clarifications, or interviews from a team of first responders or other first responder providers who will be assisting with the vetting process of this Provider Network.

This collection of providers may become an online directory for our first responders to directly access. When compiled, this directory would be housed on the 100 Club of Illinois Provider Network website and/or in our 100 Club of Illinois phone app, created for and promoted to active duty first responders and their families in Illinois. Content from your form will be utilized to compile your directory profile.

You will be contacted annually to verify that the details of your profile are still accurate and confirm your services to the first resonder community remain accurate. Please be sure to respond to these email check ins to ensure your profile stays active.

It is important for providers to give as much detail as possible so we can understand your first responder expertise and services provided. Further details about services, availability, scheduling procedures, office details, treatment modalities and competencies, etc. will give first responders more understanding of you and what their experience working with you may look like.

This form is open to all individual mental health therapists and clinicians, most commonly but not limited to LCSW's, LSW's, LCPC's, LPC's, PhD's, PsyD's. Providers should be able to demonstrate and be well versed in the first responder lifestyle. For practices that employ multiple first responder providers, we ask each individual to complete this form in order to track individual skills, specialities, and experiences.

Who or where did you hear of this clinician submission form from?*

Name*

First NameLast Name

Title at your agency:*

Licenses and credentials (abbreviations and spelled out):*

Email for potential clients to reach you*

example@example.com

Phone Number for potential clients to reach you*

Please enter a valid phone number.

Provide all current licensure and certification names and expiration dates.*

Upload supporting documentation for licensure and certifications*

Upload professional headshot photo*

Please provide your shareable bio:*

What associations are you a part of?

Practice Name*

Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please list additional office location(s) here, if applicable:

What insurances do you accept (please be specific)?*

Additional fee details (i.e., sliding scale, payment options, etc.)

Are you able to prioritize seeing first responders if you have a waitlist?*

YesNoOther

Please review the regional map and select the region(s) your practice typically serves.*

Upload photos of your office space, both interior and exterior

Do you offer telehealth?*

YesNo

Select all therapy types you provide for first responders:*

Select topics you specialize in:*

Please specify further details regarding above specialities:

Select all treatment modalities trained in and used:*

Please specify further details regarding above treatment modalities:

Please list specialties, treatment modalities, and/or populations from above that you do NOT provide or serve:

What medical treatments does your practice offer?

What medical treatments do you have a trusted, first responder friendly, direct referral for?

How do you determine appropriate referrals for the above medical treatments? What ongoing mental health care do you recommend in conjunction with these treatments?

Describe your process for assisting a client with finding an in-patient treatment facility if needed:

What in-patient treatment facilities do you recommend for first responders? Please describe why and any points of contacts you have at these locations.

At times, immediate call out support is needed for first responder critical incidents. Are you able to provide critical incident response support for:*

Are you able to provide immediate trauma or suicidal ideation assessments, (schedule permitting)?*

Yes, I am able to provide an in person, in office responseYes, I am able to provide an in person, department (or other location) response (geographically depending)Yes, I am able to provide a virtual telehealth responseYes, I am able to provide a phone responseNo, I am not able to provide that type of assessmentOther

Do you provide educational sessions for first responders? If so, please indicate what topics, range of duration, and fees:*

Percentage of first responder clients in the practice*

Percentage of first responder clients on your caseload*

Number of first responders you have served as clients*

Number of first responders you have served otherwise (training, consultation, etc.)*

Number of hours on ride alongs with first responders*

Number of hours spent in first responder oriented training*

What first responder related training and coursework have you taken? Please list (approximate) completion dates.*

Have you completed the Certified First Responder Counselor course? https://www.firstrespondercounselor.com/*

What other experiences serving first responders have you had (ride alongs, department visits, trainings, personal connections, other interactions with this population, etc.)?

How much and what first responder based continuing education do you maintain annually?*

Which of the above or other involvement and training would you be willing to partake in to receive additional experience surround first responder culture?

Which professions within first responders are you equipped to serve?*

What do you feel makes you qualified and experienced to serve the first responder population?*

From your knowledge and experience with first responders, what aspects of their work might make it difficult for them to seek counseling services?

How do you handle reporting of services for individuals mandated to seek assistance, while maintaining confidentiality requirements?

Describe a time(s) you worked professionally with a first responder:

Describe how you process heavy and/or detailed content you hear from first responders. What self care measures do you take as a provider to process what you hear and keep yourself healthy?*

Where do you see yourself in five years (geographically, professionally)?

Are there others within your organization who provide services to first responders that you would recommend? Please list their name and e-mail address.

Who else in your field do you refer first responders to? Please list all names, organizations, and e-mail addresses.

Who in your field would you NOT refer first responders to? Please list all names, companies, and why not.

Provide a description about your intake process.

Provide a description about developing a treatment plan with your clients.

If a client is not a good match for your specialties or experience, please provide a description of your referral process.

Describe a time that a client has not felt you were a good match for them. How do you respond in these circumstances to ensure care is provided elsewhere. (Or, how would you if this has not yet happened?)

#1 Professional Reference*

First NameLast Name

#1 Professional Email*

example@example.com

#1 Professional Phone Number*

Please enter a valid phone number.

#2 Professional Reference

First NameLast Name

#2 Professional Email

example@example.com

#2 Professional Phone Number

Please enter a valid phone number.

#3 Professional Reference

First NameLast Name

#3 Professional Email

example@example.com

#3 Professional Phone Number

Please enter a valid phone number.

Client #1 Reference

First NameLast Name

Client #1 Email

example@example.com

Client #1 Phone Number

Please enter a valid phone number.

Client #2 Reference

First NameLast Name

Client #2 Email

example@example.com

Client #2 Phone Number

Please enter a valid phone number.

Client #3 Reference

First NameLast Name

Client #3 Email

example@example.com

Client #3 Phone Number

Please enter a valid phone number.

Are you open to feedback regarding clinical services provided?*

YesNo

Are you open to being contacted directly by our staff if assistance is needed finding care for a first responder?*

YesNo

Are you willing to connect with the 100 Club of Illinois annually to renew/update your provider profile? (via email at a minimum)*

YesNo

I understand that by completing this form that:*

This information will be held confidential and utilized with respectThe 100 Club of Illinois reserves the right to remove you and/or the entire agency from the Provider Network at any point

Signature

Mental Health Clinician Provider Submission

Individual Provider Information

Provider Practice and Specialty Information

First Responder Experience

Intake & Client Process

Professional References

First Responder Client References

Additional Questions

Agreement