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Telepsychiatry Job Registration

Telepsychiatry Job Registration

It takes 2 minutes!

1
Name* This field is required.
Prefix
First Name
Last Name
2
Email Address* This field is required.So that we can let you know about the great psychiatry opportunities we have ready for you!
example@example.com
3
How much Telepsychiatry would you like to do?Don't worry, this is just an estimate!
Less than 9 hours/week
10-19 hours/week
20-39 hours/week
40 hours+ a week
I don't know yet!
4
Best Contact Phone Number* This field is required.
Area Code
Phone Number
5
US States where you are licensed* This field is required.Select all that apply
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
6
Professional Background* This field is required.
MD Physician
DO Physician
APRN
PMHNP
NP
other clinician
7
Are you board certified?
YESNO
8
Board Certification Status* This field is required.
MD/DO Certified in Adult Psychiatry
MD/DO Certified in Child & Adolescent Psychiatry
PMHNP-BC Board Certified Nurse Practitioner
MD/DO Certified in Addiction Psychiatry
MD/DO Board Eligible in Adult Psychiatry
MD/DO Board Eligible in Child & Adolescent Psychiatry
MD/DO Certified in Geriatric Psychiatry
MD/DO Certified in Forensic Psychiatry
Other board certification or eligibility
9
Patients you are comfortable in seeing...* This field is required.
Adults (18-65)
Adolescents (14-17)
Children (younger than 14)
Older People (over 65)
10
Would you like to upload a CV/Resume ?
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
11
Do you have any comments or feedback?Optional, you can click next to continue
12
Last Question! How did you find out about us? Did someone refer you to us?
Should be Empty:

Question Label

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