IDOW Mental Health Professionals Alliance
First Name
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Last Name
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Phone Number
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Please enter a valid phone number.
Personal Email address
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example@example.com
Professional Email address
*
example@example.com
Licensed Credential(s)
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Licensed State(s)
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List Mental Health Specialty areas
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Population age range
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How long have you been fully or provisionally licensed?
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Have you ever had your license revoked, suspended, or limited, or worked under a probationary license or consent agreement?
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Have you been censured, reprimanded, or had disciplinary action taken by an ethical standards committee, licensing board, or other board of inquiry, or is any such action currently pending or under investigation?
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Have you been indicted for, convicted of, or pleaded guilty to a crime, or are you presently under investigation for a crime?
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Jurisdiction Name:
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Jurisdictional Supervisor:
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Jurisdiction Name:
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Jurisdictional Supervisor’s email address:
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example@example.com
Has your Jurisdictional Supervisor approved the submission of your information to IDOW MHPA?
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Upload resume
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Upload current professional liability insurance certificate
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Upload current license(s) verification
*
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