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

Question Title

* First and last name:

Question Title

* Primary Credentials:

ARNP

LICSW

LMFT

LMHC

PhD

PsyD

Other (please specify below)

Question Title

* Other Primary Credentials:

Question Title

* 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)

Question Title

* Other Secondary/ Specialty Credentials:

Question Title

* Please fill out your primary practice address:

Practice Name

Address *

Address 2

City *

State *

Zip Code *

Question Title

* Primary practice phone number:

Question Title

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

Question Title

* Email address:

Question Title

* Website:

Question Title

* Do you practice at other locations?

Yes