Provider Partner Registration

Provider Partner Registration

I am interested in becoming a Provider Partner of Reset Medical and Wellness Center, whereas Reset will refer potential patients seeking additional treatment that is outside the scope of care by Reset.
Please complete each section below and attach your logo if desired.
Full Name*

First NameLast Name
Gender

MaleFemale
Company Name (if applicable)
Company Logo (if applicable)

Cancelof
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone Number
Fax Number
Mobile Phone Number
Mobile Phone Available to Patient?

YesNo
Email Address*
example@example.com
Website
www.example.com
Appointments Available Online?

YesNo
Link to Online Appointments (if applicable)
www.example.com
Types of appointments offered:

In-PersonVirtualBoth In-Person and Virtual
Type of Mental Health Professional:*

Chemical Dependency Counselor (LCDC or LCADAC)Clinical Psychologist (PhD or PsyD)Counselor in Training (CT)General PsychologistLicensed Clinical Counselor (LPCC, or LPCC-S)Licensed Clinical Social Worker (LCSW)Licensed Counselor (LPC, or LPC-S)Life coachMarriage Counselor (LMFT)Primary Care PhysicianPsychiatric Nurse Practitioner/Physician AssistantPsychiatristSocial WorkerOther
Practice Areas of Focus:*

AddictionADHDAnger ManagementAnxietyCareerChildhood TraumaDepressionEating DisordersGeneralGriefInsomniaMarriageOCDPhysical AbusePTSDSexual AbuseSexual DysfunctionTraumaOther
States Licensed to Practice:*

AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
I have been through a provider educational session with Reset and understand the treatments available to their patients.*

YesNo
Should be Empty:

Provider Partner Registration

Please complete each section below and attach your logo if desired.