Licensed Clinician Only
After you complete this form, you will be contacted to set up a time to meet.
Name
*
First Name
Last Name
Middle Name
*
Phone number
*
Email
*
example@example.com
Select all that apply:
*
Interested in billing and claim support (Independent Contractor).
Interested in employment as a supervisor (W-2).
Employer with associates requesting billing and claim support.
Other
Select all that apply:
*
AMFT
ASW
APCC
LMFT
LPCC
LCSW
Associate with a registration number.
Psychiatric Mental Health Nurse Practitioner
Child Psychiatrist
Psychiatrist
Psychological Assistant
Psychologist
Registered Nurse
Trainee
Other
Psychiatric Providers
Prescribe medication?
*
Yes
No
Not applicable
Other
Do you need a consulting physician?
*
Yes
No
Maybe
Not applicable
Other
Name of consulting physician
*
License number
*
License initial start date
*
-
Month
-
Day
Year
Date
License expiration date
*
-
Month
-
Day
Year
Date
Individual NPI
*
Do you have a CAQH number?
*
Yes
No
Unsure
Not applicable
CAQH Number
*
Do you have another license type not listed above?
California license
*
Yes
No
Not applicable
Other
Second language
*
Yes
No
Other
Language
*
Private Practice
Active Private practice:
*
Yes
No
I am setting up a private practice.
I am part of another group.
Not applicable
Other
Your services:
*
In-Person
Telehealth
Both In-Person and Telehealth
Unsure
Other
Do you have malpractice insurance?
*
Yes
No
I plan to have malpractice insurance.
Not applicable.
Other
Do you lease own office?
*
Yes
No
Unsure
I am interested in finding office space.
Not applicable
How many hours per week do you allocate to private patients?
*
Clinical areas of interest?
*
Credentialing
Credentialed individually?
*
Yes
No
Credentialed through another group?
*
Yes
No
Name of other group and location?
*
Employment
Interest working as a clinical supervisor?
*
Yes
No
Maybe
Not applicable
General
Reasons for contacting with Psychological Behavioral Health Inc:
*
I want help with collecting payments and billing insurance.
I want to consult with other clinicians.
I want to manage my own practice but with support.
I want to get paid on time every month.
Have access to referrals.
I want to get to earn more than my current situation.
I plan to work for one of the PBH clinicians or groups.
Other
How did you first learn about Psychological Behavioral Health Inc?
*
Internet site
Indeed or zip recruiter or other similar business.
Clinician affiliated with Psychological Behavioral Health Inc
Clinician NOT affiliated with Psychological Behavioral Health Inc
Psychological Behavioral Health website
Friend
Colleague
Other
Additional Comment
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
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