TheraPsych™ Institute — PMHNP Preceptorship Application

TheraPsych™ Institute — PMHNP Preceptorship Application

Applications are reviewed on a rolling basis. Please complete all required fields. Contact hello@therapsychinstitute.com with questions before submitting.
Section 1 — Applicant Information
Important — Clinical Placement and Affiliation Information
All PMHNP preceptorships and clinical affiliation agreements with universities and nursing programs are conducted through TheraPsych Behavioral Health and Wellness, PLLC — the private practice through which all clinical training, preceptorship, and supervised hours take place. TheraPsych Institute is the education, consulting, and teaching arm of this practice.

When submitting a placement request or affiliation agreement to your university or nursing program, please use the following information below:

Practice Name: TheraPsych Behavioral Health and Wellness, PLLC

Address: 116 W. 3rd Ave., Suite 1, Gastonia, NC 28052

Clinical Contact Email: Sbaker@therapsychcare.com

Business Phone: 704-689-0393

Business Fax: 1-855-978-2444

Preceptor: Shukairo Baker, APRN, PMHNP-BC, PMHNP-C, CNE, LCSW, LCAS

If you do NOT have a compact RN license, or license to practice in NC, you will need to obtain one. We do have a satellite office in SC. Please submit the information above to your university clinical placement coordinator or affiliation office as soon as your application is approved. Your placement cannot be confirmed until your university has processed and approved the affiliation agreement with TheraPsych Behavioral Health and Wellness, PLLC. Note: TheraPsych Institute manages all applications, scheduling, payment, and student communication. TheraPsych Behavioral Health and Wellness, PLLC is the licensed clinical entity under which all supervised hours and affiliation agreements are executed.
Full Legal Name

First NameMiddle NameLast Name
Preferred Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
State of Residence
Current Nursing License Type
Nursing License Number (if applicable)
State(s) of Nursing Licensure
Current Therapy or Counseling License(s) Held

Other
If Other license, please specify
Section 2 — Program Information
PMHNP Program Name and University
Program Accreditation
Expected Program Start Date

MonthDayYear
Date
Expected Graduation Date

MonthDayYear
Date
Enrollment Status
Total Clinical Hours Required by Your Program
Clinical Hours Completed to Date
Clinical Hours Remaining
Preferred Preceptorship Start Date

MonthDayYear
Date
Preferred Preceptorship End Date

MonthDayYear
Date
Preferred Days for Clinical Shifts
Preferred Shift Times
How Did You Hear About TheraPsych™ Institute?
Section 3 — Clinical Background
Describe Your Current or Most Recent Clinical Role
Years of Clinical Experience
Patient Populations You Have Worked With
Describe Your Clinical Strengths and What You Bring to This Preceptorship
Skills and Competencies You Hope to Develop During This Preceptorship
Section 4 — Payment Plan Selection
All payment amounts are calculated based on your contracted clinical hours and selected payment plan. Enter your total hours below and select a plan to see your exact payment schedule. Minimum 40 hours required. Please note: Your space is secured only when your payment is received. Submission and/or approval of application alone does not mean you have secured your spot. Please remit payment based on plan decided upon at the time of application submission. Payments may be remitted via Zelle to sbaker@therapsychinstitute.com, or payable by debit or credit card via Stripe invoice. You may choose which payment method you are electing below.
Total Contracted Clinical Hours (minimum 40 hours)
Select Your Payment Plan
Select Your Payment Method
Plan 1 Total Due at Submission — $10 per hour
Plan 2 — Payment 1 of 2 Due at Submission
Plan 2 — Payment 2 of 2 Due 30 Days Before Semester Start
Plan 2 Total — $11 per hour
Plan 3 — Payment 1 of 3 Due at Submission
Plan 3 — Payment 2 of 3 Due 30 Days After Submission
Plan 3 — Payment 3 of 3 Due 30 Days Before Semester
Plan 3 Total ($12/hr x hours)
SEMESTER START DATE RULE: If your program semester begins within 30 days of your application submission date, full payment under your selected plan is due at time of submission to secure your placement.

REFUND POLICY: All payments are non-refundable for any reason with one exception: if your university denies your clinical placement after payment has been submitted, a refund minus a $75 administrative processing fee will be issued within 2-3 business days plus any applicable bank processing time. No other refunds will be issued under any circumstances including program withdrawal, personal emergencies, schedule conflicts, or failure to complete contracted hours.
I have read and agree to the payment terms and refund policy above
Section 5 — Additional Information
Scheduling Constraints or Special Circumstances
Anything Else We Should Know About Your Application or Goals
How Would You Describe Your Learning Style?
Documented Disabilities or Accommodations Needed?
Section 6 — Agreements and Electronic Signature
Accuracy Certification
Placement Contingency Acknowledgment
Intellectual Property Agreement
Terms and Conditions Agreement
Electronic Signature — Type your full legal name as your electronic signature

First NameLast Name
Date of Signature

MonthDayYear
Date
Thank you for applying to the TheraPsych Institute PMHNP Preceptorship Program. You will receive a confirmation email upon submission. Questions before submitting? Email hello@therapsychinstitute.com — Shay Baker, APRN, PMHNP-BC, PMHNP-C, CNE, LCSW, LCAS | Founder, TheraPsych Institute | Elevate Practice. Empower Minds. Expand Possibility.
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TheraPsych™ Institute — PMHNP Preceptorship Application

Section 1 — Applicant Information

Important — Clinical Placement and Affiliation Information

Section 2 — Program Information

Section 3 — Clinical Background

Section 4 — Payment Plan Selection

Section 5 — Additional Information

Section 6 — Agreements and Electronic Signature