Clinician Applicants Only Focus of Practice | Right Path Behavior Health Services

Focus of practice:

Age Groups

ChildernadolescentsAdultsGeriatric

Disability Groups

MHDDSAThis information is requested for quality improvement purpose.

Licencure/Certification:

Lic./Cert type.:

Lie./Cert. #

Currently Pursuing Lic./Cert:

Type

Expected Date of Completion

Other Cardentials (List):

Continuing Education:

*** Please attach completed CEU/Training Log:

Attached

Specialized Training and Expertise:

Please Check (or list) the specialties below which represent at least 20% or more of consumers who you have worked with and/or in which you have received specialized training.

Other

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).

Other level of Care and Experience:

Physicians Only: Copies of Information Must Be Attached)

Fedral DEA Number

State

Board Cirtificaton

Specialty

Name of Psychiatric Recidency Training Program

Copies of license(s), certifications, and certificate of completion attached.Check here if you are NOT planning to take Board Examinations

List Hospitals you have admitting priviledges to

Certified Nurse Practitioners Only(Please submit the Following Information)

Copy of CNP Certificate for Mental HealthCopy of DEA License to prescribe Medications

List of Supervising Phsician

License#