Sunaura Therapy Collective Onboarding Application

Sunaura Therapy Collective Onboarding Application

Complete this onboarding application using the wording and order shown in the source PDF. Include all required fields, attachments, attestations, authorizations, payment setup, and internal-use-only fields.
Personal & Contact Info
Legal Name

First NameMiddle NameLast Name
Preferred Name
Email Address
example@example.com
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
Date
Place of Birth
Full SSN
Credentialing & IDs
Provider Taxonomy/Type
State Medical License Number
State Medical License Issue Date

MonthDayYear
Date
State Medical License Expiration Date

MonthDayYear
Date
DEA Registration Number
DEA Registration Expiration Date

MonthDayYear
Date
NPI Number
Medicare ID Number
Medicaid ID Number
Professional License / Credential Number
Certification Number
Certification Expiration Date

MonthDayYear
Date
Upload Copy of State License

Cancelof
Upload Copy of DEA Registration

Cancelof
Confirmation of Credential Information Accuracy

Other
Authorization to Verify Credentials

Other
Licensure
State / Jurisdiction
License Type
License Number
License Issue Date

MonthDayYear
Date
License Expiration Date

MonthDayYear
Date
Current License Status
Renewal Required
Next Renewal Date

MonthDayYear
Date
Primary Practice State
License Title / Designation
Board / Issuing Authority
Any Restrictions on Practice
If yes, describe restrictions
Has this license ever been disciplined?
If yes, explain discipline
Additional licensure notes
Education
School Name
Degree Type
Degree Major / Field of Study
Graduation Date

MonthDayYear
Date
Malpractice
Claims History
Upload Malpractice Declarations Page

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Confirmation

Other
Clinical Profile
Specialty areas of practice

Other
Populations served

Other
Clinical modalities offered

Other
Service formats provided

Other
Client age groups

Other
Languages spoken in clinical work

Other
Areas of clinical focus

Other
Certifications held

Other
Summary of clinical experience
Experience with specialty populations
Experience with treatment modalities
Experience providing telehealth services
Experience with group or family work
Additional clinical skills or approaches
Years of clinical experience
Approximate weekly caseload capacity
Clinical interests or preferred caseload
Availability
Days Available
Hours and Scheduling Availability
Attestations
I acknowledge that the information provided in this application is true and complete to the best of my knowledge.
I understand that any falsification, omission, or misrepresentation may result in rejection of my application or termination of my relationship with Sunaura Therapy Collective.
I agree to notify Sunaura Therapy Collective promptly of any changes to my contact information, licensure status, clinical credentials, or availability.
I acknowledge that I am responsible for maintaining current, active, and unrestricted credentials required for the services I provide.
I consent to verification of the information provided in this application, including education, employment, licensure, and references.
I understand that completion of this application does not guarantee acceptance, placement, or assignment of clients.
Applicant Signature
Date Signed

MonthDayYear
Date
Primary work email for system setup
example@example.com
ACH/Payment Setup
Account Holder Name

First NameMiddle NameLast Name
Bank Name
Account Number
Routing Number
Account Type
Payment Authorization
Payment Instructions or Special Notes
Authorization Signature
Authorization Date

MonthDayYear
Date
Other Documents
Resume or Curriculum Vitae

Cancelof
Government-Issued Photo Identification

Cancelof
Professional License Document

Cancelof
Board Certifications or Specialty Certifications

Cancelof
Malpractice Insurance Declarations Page

Cancelof
Malpractice Claims History Letter

Cancelof
Additional Supporting Attachments

Cancelof
Authorizations
Background Check Consent

I acknowledge that additional information or authorization may be requested if needed.
Confidentiality Acknowledgment

I understand that confidentiality obligations continue after my association ends.
Consent to Electronic Communication

I acknowledge that I am responsible for keeping my contact information current.
Applicant Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Sunaura Therapy Collective Onboarding Application

Personal & Contact Info

Credentialing & IDs

Licensure

Education

Malpractice

Clinical Profile

Availability

Attestations

ACH/Payment Setup

Other Documents

Authorizations