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Behavioral Health Provider Questionnaire
1.
Name, Degree
2.
HNE 5-Digit Provider ID#
3.
Email address
4.
Website address
5.
Complete office hours detail
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
6.
Extended office hours
Evening hours
Weekend hours
7.
Office handicapped accessible?
Yes
No
8.
Do you E-Prescribe, if applicable?
Yes
No
9.
Do you have Electronic Medical Records (EMRs)?
Yes
No
10.
Do you treat the Hearing Impaired / offer Sign Language?
Yes
No
11.
Languages spoken by provider in addition to English
12.
Are you accepting new patients?
Yes
No
13.
What ages do you treat?
14.
Services provided - Check all that apply
ADOLESCENTS
ADULTS
CHILDREN
GERIATRICS
ACCEPTANCE AND COMMITMENT THERAPY (ACT)
APPLIED BEHAVIORAL ANALYSIS
AUTISM SPECTRUM DISORDERS (ASD) DIAGNOSIS & TREATMENT
BISEXUAL/GAY/LESBIAN/TRANSGENDER
COGNITIVE BEHAVIORAL THERAPY (CBT)
DIALECTICAL BEHAVIOR THERAPY (DBT)
EATING DISORDER TREATMENT
EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR)
GROUP THERAPY
MARRIAGE AND FAMILY THERAPY
NARRATIVE THERAPY
NEURO-PSYCHOLOGICAL TESTING
OBSESSIVE-COMPULSIVE DISORDER
POST-TRAUMATIC STRESS DISORDER
PSYCHODYNAMIC PSYCHOTHERAPY
PSYCHOLOGICAL TESTING
REACTIVE ATTACHMENT DISORDER (RAD)
REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (RTMS)
SUBSTANCE ABUSE
TRAUMA FOCUSED COGNITIVE BEHAVIORAL THERAPY (TFCBT)
TRAUMA INFORMED TREATMENT
Please visit the Provider Search on HNE.com to view your current listing and notify us of any additional changes. (http://www.healthnewengland.com/Provider_Lookup_Direct/Default.aspx)