Washington's Mental Health Referral Service for Children and Teens: Provider Survey

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* First and last name:

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* Primary Credentials:

ARNP

LICSW

LMFT

LMHC

PhD

PsyD

Other (please specify below)

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* Other Primary Credentials:

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* Secondary/ Specialty Credentials:

BCBA

CDP

CEDS

CMHS

DDMHS

EMMHS (please specify in "other" any specific population designation, IE- African American. American Indian, Alaskan Native, Asian/Pacific Islander, Hispanic, etc.)

IMHS

PMHNP

Other (Please specify below)

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* Other Secondary/ Specialty Credentials:

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* What is your gender?

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* Religious Affiliation

Buddhist

Christian

Hindu

Islam

Jewish

LDS (Latter-Day Saints)

Other Spiritual or Religious Affiliations

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* Please fill out your primary practice address:

Practice Name

Address *

Address 2

City *

State *

Zip Code *

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* Primary practice phone number:

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* Secondary phone number for primary practice (if any):

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* Email address:

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* Website:

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* Do you practice at other locations?

Yes