Join us at Confidant Health

Join us at Confidant Health

We're so thrilled you're interested in joining the Confidant provider network.
Full name:*

First NameLast Name
Best email:*
example@example.com
Cell phone number:*
Please enter a valid phone number.
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:*

MonthDayYear
City of Birth:
State of Birth:
What type of license(s) do you have currently?*

LICSWLCSWLCSW-CLISW-CPCIPSWLPCLCMHCLMHCLMFTLCADCLADACFNPFNP-BCPMHNPPMHNP-BCCNMWHNP-BCAGNPAGACNPAGPCNPCARN-AP
What state(s) are you currently licensed in?*

ConnecticutFloridaMaineMarylandNew HampshireNew JerseyPennsylvaniaTexasVirginiaWashington DCOther
Have you accepted insurance before?*

YesNo
Have you lost your license before?*

YesNo
Have you been convicted of a felony?*

YesNo
Do you have any outstanding malpractice claims?*

YesNo
Provider Type
How did you hear about Confidant Health?
Upload your resume here:

If you don't have it now, leave this blank and we'll request it later.
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Which Confidant Employee should we be thanking?
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