If you are a mental health provider or organization that serves children and adolescents within the state of Indiana, we kindly ask that you take a moment to complete this form. The information you provide will be added into INAAP's CARE Program database of mental health providers. The database will grow with every child served, and operate as a tool to guide both families, and medical professionals, in referring Indiana children to the services they need. 

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* 1. First Name

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* 2. Last Name

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* 3. Credentials

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* 4. We kindly ask that providers disclose their gender/gender identity below to assist us in matching clients to services that will best meet their needs. We also understand and respect the choice not to disclose this information.

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* 5. We kindly ask that providers disclose their race/ethnicity to assist us in matching clients to services that will best meet their needs. We also understand and respect the choice not to disclose this information.

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* 6. Please provide the name and address of your practice. You are welcome to list additional affiliations and addresses where you serve clients in the additional information section at the end of this form.

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* 7. What is the best phone number and email address for new or prospective clients to contact?

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* 8. When does your practice serve clients?

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* 9. What are the operating hours of your practice?

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* 10. Please provide any additional office hour information/availability.

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* 11. Are you currently accepting new clients? If “yes”, what is the current waiting period for clients to be scheduled for an appointment?

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* 12. What are the age requirements for the clients that you serve?

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* 13. What languages are spoken in your practice?

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* 14. What types of insurance and forms of payment are accepted at your practice?

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* 15. What services are offered at your practice?

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* 16. What types of treatment are offered at your practice?

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* 17. What types of therapy are offered at your practice?

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* 18. Does your practice specialize in treating any of the following?

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* 19. Please use the space below to provide any additional information about yourself, or your practice.

Thank you for taking the time to complete this form. We hope that you will join us in our mission, the attainment of optimal physical, mental and social health for all infants, children, adolescents and young adults. It is to this end, that the members of the American Academy of Pediatrics dedicate their efforts and resources.

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