Professional & Licensure Information

What is your profession?*

CounselorPsychiatristPsychologistSocial worker

Degree*

What service(s) do you provide?*

Primary License State*

Primary License Number*

Additional LicensesPlease add state (or abbreviation) and license number

Which modes of therapy do you provide? *

Virtual onlyVirtual and in-personIn-person only

Do you have an interjurisdictional compact that allows you to practice teletherapy across state lines? *

NoYes

What is your NPI (National Provider Identification) number?

What is your EIN (Employer Identification Number)?*If you have not set up an independent business, this would be your social security number (SSN)