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Provider Information
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Name
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Phone Number
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Email
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Address
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City
State
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Date Available
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Licensed Discipline
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License Number
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Primary Practice Information
Practice Name
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Practice Address
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State
Zip Code
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Practice/Client Phone Number
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Email
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Client Availability Information
Please Days and Times you would be available to see SAFE Clients
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Clinical Expertise/Practice Focus Areas
Select All That Apply
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Addiction
Eating Disorders
PTSD
Teen/Adolescent Counseling
Anxiety Disorders
Grief & Bereavement
Traumatic Brain Injury (TBI)
Child Therapy
Substance Abuse
Stress Management
Marriage & Family Therapy
Domestic Violence
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Sexual/Physical Abuse
Mood Disorders
Maternal Mental Health
OCD
Occupational Issues
Pain Managment
Parenting Issues
Depression
List Any Other Areas of Clinical Expertise/Focus Areas
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Preferred Treatment Modalities
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EMDR
CBT
ACT
CPT
Mindfulness
Solution Focused Therapy
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Please List Any Additional Certifications You Hold
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Military Service
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Branch of Service
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Dates of Service
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Rank at Discharge
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To:
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Type of Discharge
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If Other Than Honorable Please Explain
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Provider Attestation Statement
The provided information and the attached documents contain detailed and specific information relating to
professional competence. All of the information that I have provided and the responses that I have given are correct and complete to the best of my knowledge and belief. I understand willful falsification or willful omission of this information will be grounds for rejection or termination.
I release SAFE, its representatives, and any individuals or entities providing information to SAFE from liability for any act or omission related to the evaluation or verification contained in this application provided SAFE its representatives and individuals providing information to SAFE act in good faith and without malice. I further agree to notify SAFE of any change to the information provided in this application within 30 days of any such change. I understand that any information provided in this application that is not publicly available will be treated as confidential by SAFE.
I agree to support SAFE, and those receiving clinical services offered through SAFE, by providing quality clinical care. As such, I agree to an annual audit of randomly selected case files to (i) ensure the integrity of appropriate requirements in record maintenance as stipulated by HIPPA and other laws surrounding a client’s right to privacy, and (ii) establish continuity of care among providers associated with SAFE in promoting excellence through clinical practice.
I agree to notify SAFE immediately in writing of the occurrence of any of the following: (i) the unstaid suspension, revocation, limitation, restriction or non-renewal of my license to practice in any state; or (iii) any cancellation, limitation, restriction or non-renewal of my professional liability insurance coverage.
I further agree to notify SAFE in writing, promptly and no later than fourteen (14) calendar days from the occurrence of any of the following: (i) receipt of written notice of any adverse action against me by the applicable State Regulation and Licensing or the applicable State Medical Examining Board taken or pending, including but not limited to, accusation filed, temporary restraining order, or imposition of any interim suspension, probation or limitations affecting my license to practice; or (ii) any adverse action against me by any Healthcare Organization which has resulted in the filing of a report with the applicable State Regulation and Licensing or the applicable State Examining Board, or a report with the National Practitioner Data Bank; or (iii) any material reduction in my professional liability insurance coverage; or (iv) receipt of written notice of any legal action against me, including, without limitation, any filed and served malpractice suit or arbitration action; or (vi) my conviction of any crime (excluding minor traffic violations); or (vii) my receipt of written notice of any adverse action against me under the Medicare or Medicaid programs, including, but not limited to, fraud and abuse proceedings or convictions.
I authorize SAFE and its agents and any individual or entity providing information to SAFE to investigate and evaluate my provider application, and consult with any person, organization, or entity that has, or could have any information, data, or documents regarding my background, competence, and credentials.
Disclaimer and Signature
By typing my name below, I certify that my answers are true and complete to the best of my knowledge.
If this application leads to contractual services, I understand that false or misleading information in my application or interview may result in my release
.
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DONATE
About SAFE
WHAT WE DO
WHO WE ARE
CLIENT TESTIMONIES
GET INVOLVED
EVENTS
CAREERS
INTERNSHIPS
CLIENT PORTAL
GIVE FEEDBACK
Request Services
Contact Us
Mental Health Resources
Local Resources
Crisis/Resources
Military/Veterans
First Responder Resources
Drug and Alcohol Misuse
Other Resources