Frontline Clinician Provider Submission

Frontline Clinician Provider Submission

100 Club of Illinois Clinician submission form for Frontline Provider Network
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.

Provider Network Process:

The 100 Club of Illinois is currently collecting mental health clinical provider details to build a list of providers who are well trained and competent in serving the first responder and first responder family population. 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.

After submitting your application you will be contacted for an interview with our first responders and first responder providers who will be assisting with the vetting process of this Provider Network.

This collection of providers will become an online directory for our first responders to directly access. This directory will 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 responder community remain accurate.

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.

For practices that employ multiple first responder providers, we ask each individual to complete this form in order to track individual skills, specialties, and experiences.
Individual Provider Information

Details in the section are collected in regards to the individual provider submitting this form and used for your Provider Network Profile.
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*

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Upload professional headshot photo*

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Please provide your shareable bio:*
Provider Practice and Specialty Information

Details in the section are collected in regards to the individual provider submitting this form and used for your Provider Network Profile.
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.)
Please review the regional map and select the region(s) your practice typically serves.*

NortheastNorthwestWest CentralCentralEast CentralSoutheastSouthwestAll of the Above
Do you offer telehealth?*

YesNo
Select all therapy types you provide for first responders:*

ChildrenCouplesFamiliesGroupIndividualsOther
Select topics you specialize in:*

Addiction and Substance UseAnxietyDepressionFamily ConcernsGriefMarriage RelationshipsOther RelationshipsParentingPTSD/TraumaSleep DisturbanceOther
Select all treatment modalities trained in and used:*

Animal Assisted TherapyArt/Expressive TherapyBehavioral TherapyBiofeedbackClient-CenteredCognitive Behavioral TherapyDialectical Behavior TherapyEye Movement Desensitization and ReprocessingExperiential TherapyExposure TherapyMindfulness/Meditation/BreathworkMotivational InterviewingNeurofeedbackSolution-FocusedOther
What medical treatments does your practice offer?

Brain Stimulation: DBS, ECT, TMSKetamine treatmentPrescription medicationStellate Ganglion BlockNo medical treatments offered at my practiceOther
At times, immediate call out support is needed for first responder critical incidents. Are you able to provide critical incident response support for:*

An individual first responderAn individual family memberA group of first respondersA family groupA department roll callI am not able to provide critical incident responseOther
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
Which professions within first responders are you equipped to serve?*

Correction OffiicerDispatchFirefighterLaw EnforcementParamedicSurvivor Families (families of fallen first responders)Other
What do you feel makes you qualified and experienced to serve the first responder population?*
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 or where did you hear of this clinician submission form from?*
Agreement
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

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Frontline Clinician Provider Submission

Individual Provider Information

Provider Practice and Specialty Information

Agreement