Love & Serenity Counseling Services
Contractor Application
Join our Team
Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Complete SS Number
Languages fluently spoken in addition to English
What other licensed do you hold in the mental health field?
What is your NPI Number
If you are licensed what is your CAQH Number CAQH: Create if you dont have ( or leave blank we can help you) https://proview.caqh.org/PR/Registration/SelfRegistration
If you are licensed what is your Availity Number Availity: Create if you dont have (or leave blank we can help you) Availity: https://apps.availity.com/web/onboarding/availity-fr-ui/#/login
If you are licensed what is your PECOS Number PECOS: Create if you dont have (or leave blank we can help you) PECOS: https://pecos.cms.hhs.gov/pecos/login.do#headingLv1
What is your license number
Professional Information, What are you currently licensed as?
Licensed Professional Counselor (LPC)
Licensed Mental Health Counselor (LMHC)
Licensed Clinical Social Worker (LCSW)
Licensed Marriage and Family Therapist (LMFT).
Advanced Practice Registered Nurses (APRNs)
Physicians (MDs and DOs)
Nurse practitioners (NPs)
Physician assistants (PAs)
Not licensed by have a master's in Counseling and Psychology
Pre-licensed
If you have more than one master's degree, as it relates to counseling, please list below
If you are licensed and are credentialed, provide the insurance company's name an your provider number for each company.
Emergency contact person
First Name
Last Name
Emergency contact phone number
Format: (000) 000-0000.
License Number
Issuing State:
-
Month
-
Day
Year
Date
License Expiration Date:
Are you fully insured for professional liability/malpractice coverage?
Yes
No
Type of Provider
Please Select
LPC
Clinician
Social Worker
Family Therapist
Behavioral Health
Occupational Therapist
Specialty or Care Area
Please Select
Family Counseling
Group Counseling
Individual Therapy
Group Therapy
Telehealth
All of the Above
Supervision
What type of Service can you provide
Family Counseling
Therapist
Individual Therapy
Group Therapy
Telehealth
Recovery Coach
Community Support Program
Recovery Support Navigator
Supervision
All of the Above
Are you currently credentialed with any insurance panels?
Yes
No
Resume or CV
Degree Earned:
Graduation Date:
-
Month
-
Day
Year
Date
Additional Certifications or Specialized Training:
Populations Served (Check all that apply):
☐ Children
☐ Adolescents
☐ Adults
☐ Couples
☐ Families
Therapeutic Modalities Used:
☐ CBT
☐ DBT
☐ Trauma-Informed
☐ Faith-Based
☐ Other: _______________
Experience: Years of Clinical Experience:
Please indicate highest number of hours you are able to work in a day
Please Select
4
6
8
12
Work Status
Please Select
Actively practicing
Not actively practicing, but not retired
Retired
Graduate School Name
Degree Earned:
References Please provide two professional references: Name: Relationship: Phone/Email:
☐ Resume or CV
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☐ Headshot Picture
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☐ Copy of LPC License
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Signature
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