Hope's House Provider Bio Form
Hope’s House is committed to connecting first responders and their families with qualified mental health professionals who understand the unique challenges they face. If you are interested in partnering with us as a provider, please complete the form below. This information will help us build a comprehensive referral network to ensure those in need receive the right support. Thank you for your willingness to be part of this mission. For any questions please contact us at tyler@hopeshouse.life
Name
First Name
Last Name
Practice Name
Practice Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Website (If Applicable)
Mode of Treatment
In-person
Telehealth
Both
States Licensed to Practice
Credentials and Licenses
List Degrees, Certifications, and License Numbers
Specialties and Areas of Focus
(e.g., PTSD, trauma, anxiety, depression, first responder mental health, grief counseling, family therapy, etc.)
Modalities and Approaches Used
(List primary therapeutic approaches, e.g., Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), EMDR, NLP, Solution-Focused Therapy, etc.)
Insurance Accepted and Payment Options
(List insurance providers accepted, sliding scale options, private pay, etc.)
Experience with First Responders / Trauma / PTSD:
(Briefly describe relevant experience working with first responders, trauma survivors, or those with PTSD)
Availability for Referrals:
(Indicate whether you are currently accepting new clients and any limitations on availability)
Additional Information:
(Any other details that may be relevant, such as group therapy offerings, workshops, crisis intervention services, or community programs)
Submit
Should be Empty: