Expert Registration Form

PediaSource Expert Application Form

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Provider Information

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Name: *

First Name Last Name
Email Address: *
NPI No.:
Medical Malpractice/Business Insurance Provider: *
Medical Malpractice Policy No.:
Medical Malpractice Group No.:
State Drivers’ License No.: *
State Professional License No.:
Current License Expiration Date *

Month Day Year
Date
Address for PediaSource to send correspondence: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address for referred client appointments: *

Same as above New address
Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone number for PediaSource to contact you: *
Phone number for PediaSource's clients to contact you: *
Insurances accepted by you(r) practice (check all that apply): *

None Kaiser Foundation Anthem, Inc Humana Cigna Health Blue Cross B.S. CVS HCSC Centene Corp WellCare Molina Healthcare Other
Indicate your cash rates for the following fields.
Initial:
Initial Weekends/Nights/Holidays:
Follow-up:
Follow-up Weekends/Nights/Holidays:
Twins Initial:
Twins initial Weekends/Nights/Holidays:
Twins Follow-up:
Twins Follow-up Weekends/Nights/Holidays:
Insurance rates for eval:
Insurance rates for treatment:
Bio/Profile Form

Please DO NOT list the name of your practice. We promote experts personally, not their practices.
This information will be shared with parents/caregivers looking for a specialist.
Upload a clear photo of yourself (a full front view of your head and shoulders, in front of a clear background).

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Are you a: *

Clinical Psychologist Lactation Specialist Learning Specialist Occupational Therapist Potty-Training Specialist Sleep Specialist Speech Pathologist
Indicate your skills as a Clinical Psychologist: *

ADHD Addiction/Substance Use Adoption Anger Management Anxiety Autistic Spectrum Disorders Behavioral Issues Bipolar Disorder Borderline Personality Chronic Illness/Pain Coping Skills Depression Developmental Disorders Divorce/Family Conflict Eating Disorders Grief Narcissistic Personality Obsessive-Compulsive (OCD) Oppositional Defiance Parenting Peer Relationships Pregnancy, Prenatal, Postpartum Self Esteem Self-Harming Sleep or Insomnia Spirituality School Refusal Suicidal Ideation Transgender/LGBTQ Tourettes Trauma/Abuse Other
Indicate your skills as a Lactation Specialist: *

Difficult or Ineffective Latch Engorgement Help and resources for tongue or Lip tie High Infant Weight Loss Jaundiced Infant Low Birth Weight Infant Low Milk Supply Mastitis Oversupply Plugged Ducts Poor infant weight gain Pre-term infants Previous breast surgery Returning to work Sleepy Infant Sore or Damaged Nipples Thrush Transfer to at-breast feeding Twins/multiples Other
Indicate your skills as a Learning Specialist: *

Dyslexia Learning plans Math skills Reading comprehension and writing Writing IEPs Other
Indicate your skills as a Potty-Training Specialist: *

Bowel training Bowel withholding Constipation Diapers Floor potties Pull-ups Soiling Toilet seats Urine Training Other
Indicate your skills as an Occupational Therapist: *

ADHD Autism/Asperger Syndrome Developmental Disorder/Delays Down's Syndrome Dyspraxia / Developmental Coordination Disorder Executive Functioning Handwriting Learning difficulties Neuromuscular Conditions Neuromuscular Disorders (Spina Bifida,Cerebral Palsy etc.) Sensory Processing Disorders Other
Indicate your skills as a Sleep Specialist: *

Age appropriate sleep schedules Cosleeping Day and night Training Optimal sleep environment Sleep Refusal Strategies for self-soothing Other
Indicate your skills as a Speech Pathologist: *

Articulation disorders Cognitive-communicative disorders Communication and swallowing disorders related to other issues Expression and comprehension in oral and non-verbal contexts Language delays and disorders Fluency disorders Phonological awareness, decoding Phonology and motor speech disorders. Pre-literacy and literacy skills Reading comprehension and writing. Reasoning, problem solving and executive functions Stuttering Social communication skills Speech delays and disorders Swallowing and feeding disorders in adults, children and infants. Voice and resonance disorders. Other
How many years of experience do you have?: *

3-5 years 5-10 years 10-15 years 15-20 years 20+ years
What age group do you most frequently work with? *

0-5 years 5-10 years 10-12 years 12-18 years Other
Which settings do you have experience in?: *

Clinic Home Virtual/Telehealth School Other
List your disciplines and credentials (e.g. Licensed Psychologist, PhD, IBCLC): *
List your education, certificates, training, and other documented skills: *
Please tell us anything else you would like parents/caregivers to know about you and/or your work:

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PediaSource Expert Application Form

Provider Information

Bio/Profile Form