Mental Health Professional (MHP) Application

PRACTITIONER APPLICATION INFORMATION

Please complete the following information. This information will remain CONFIDENTIAL.

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* 1. Application Date:

Date:

Date

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* 2. First Name

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* 3. Last Name

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* 4. Preferred Email Address

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* 5. Preferred Phone Number

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* 6. Practice Name

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* 7. Practice Web Site

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* 8. Practice Street Address

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* 9. Practice City

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* 10. Practice County

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* 11. Practice State

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* 12. Practice Zip Code

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* 13. Practice Phone Number

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* 14. Degrees

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* 15. Mental Health License Number

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* 16. State of License Issuance - Mental Health

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* 17. Mental Health License Renewal Date

Date / Time

Date

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* 18. Marriage & Family License Number

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* 19. State of License Issuance - Marriage & Family

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* 20. Marriage & Family License Renewal Date

Date / Time

Date

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* 21. Other Licenses & Certifications

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* 22. Years in Practice

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* 23. Practice Specialty

Specialty 1

Specialty 2

Specialty 3

Specialty 4

Specialty 5

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* 24. Insurances Accepted

Insurance 1

Insurance 2

Insurance 3

Insurance 4

Insurance 5

Insurance 6

Other

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* 25. Do you have the ability to provide video sessions with clients?

Yes

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* 26. Familiarity with Law Enforcement

Former LEO

Family Member of LEOs

Friends with LEOs

Treated LEOs

Treated other First Responders

Treated Military Veterans

Other (please specify)

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* 27. Usual Office Hours

Daytime

Evenings

Weekends

Other (please specify)

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* 28. Do you offer Video Counseling services?

Yes

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* 29. Would you be willing to provide a Professional Discount when treating Law Enforcement Officers (LEOs)?

Yes

Note Sure

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* 30. Would you be willing to attend the BlueLine Mental Health Provider Training (1-day)?

Yes

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* 31. Would you be willing to do a Ride-Along for a shift with a LEO?

Yes

I do not know what a Ride-Along is

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* 1. Application Date:

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* 2. First Name

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* 3. Last Name

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* 4. Preferred Email Address

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* 5. Preferred Phone Number

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* 6. Practice Name

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* 7. Practice Web Site

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* 8. Practice Street Address

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* 9. Practice City

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* 10. Practice County

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* 11. Practice State

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* 12. Practice Zip Code

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* 13. Practice Phone Number

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* 14. Degrees

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* 15. Mental Health License Number

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* 16. State of License Issuance - Mental Health

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* 17. Mental Health License Renewal Date

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* 18. Marriage & Family License Number

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* 19. State of License Issuance - Marriage & Family

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* 20. Marriage & Family License Renewal Date

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* 21. Other Licenses & Certifications

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* 22. Years in Practice

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* 23. Practice Specialty

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* 24. Insurances Accepted

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* 25. Do you have the ability to provide video sessions with clients?

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* 26. Familiarity with Law Enforcement

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* 27. Usual Office Hours

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* 28. Do you offer Video Counseling services?

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* 29. Would you be willing to provide a Professional Discount when treating Law Enforcement Officers (LEOs)?

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* 30. Would you be willing to attend the BlueLine Mental Health Provider Training (1-day)?

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* 31. Would you be willing to do a Ride-Along for a shift with a LEO?

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* 32. Additional Comments