• Focus of practice:

    This information is requested for quality improvement purpose.
  • Licencure/Certification:

  • Continuing Education:

    *** Please attach completed CEU/Training Log:
  • Specialized Training and Expertise:

  • Behavioral Health Level of Care Experience ( if you have 1 or more year(s) in the below levels of care, check applicable item, and years of experience).

  • Physicians Only: Copies of Information Must Be Attached)

  • Board Name
  • Certified Nurse Practitioners Only(Please submit the Following Information)