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Non-Behavioral Health Provider
Provider Information
First name
*
Last name
*
Please provide your credentials:
*
I identify as:
*
Female
Male
Non-Binary
Prefer to Self Identify
Prefer not to disclose
Clinician Contact Email (will not be shared with clients)
*
Clinician Contact Phone (will not be shared with clients)
*
Provider Offerings
Please detail your service offerings:
*
Is there a specific population that you work with:
*
Do you have any trauma-informed training in your area of work:
*
Yes
No
Can you provide services in any other languages besides English?
*
Client Contact Information
Website URL
*
Link to appointment scheduling page (if you have one)
Intake Email (for clients)
*
Intake Phone Number (for clients)
*
Insurance Information
Which insurances are you in network with (if applicable)?
*
None, Self Pay Only
Aetna
Allegiance
BCBS Blue Choice
BCBS PPO
Cigna
Golden Rule
Loyola Physician Partners
Medicaid
Medicare
Pathways (UC Chicago)
UMR
United Healthcare HMO/PPO
Other
Please share your self pay rates and whether you have sliding fee scale
Location Information
How are you providing services
*
In-Person Only
Virtually Only
Hybrid (In-Person and Virtually)
Networking Information
Would you like to schedule a virtual meeting with Suzanne Muirheid, CEO and Clinical Director, to explore opportunities for collaboration?
*
Yes, I'd love to get a meeting set up.
No thank you--we've already touched base.
Use this section to provide any pertinent practice updates for our team to know (i.e. new support groups, growth and more).
Which Calm Mind Counseling Center provider sent you this form?
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