Clinician Form - Washoe County Children's Mental Health Consortium

Therapist-Clinician Form

This form is for individual therapists, psychologists, psychiatrists, and certified life coaches that work with youth to list their services in the YouthWell directory. Once approved, we will reach out to you so you can add your listing to the directory.

Email our team at wccmhconsortium@gmail.com if you have any questions.

"*" indicates required fields

Name*

First Last

Email*

Work Phone*

Work Address*

Street Address City State ZIP Code

Website

Please share the link to your website if you have one.

Credentials*

Please include any degrees and the licenses you hold.

I AM A*

Years in practice working with YOUTH*

How many years do you have specifically working with youth, ages 5-25 in practice (including your internship/residency/post-doctoral)?

Specialities - Modalities*

Please list any specialties related to youth and families. Do you do EMDR, play therapy, bereavement/grief, sexual assault, eating disorders, substance use, etc.

AGES of YOUTH

Please share what ages you serve in your practice. We would like to have a sense of where your experience lies.

0-4

5-7

8-11

12-13

14-17

18-25

Rates & Fees*

Please specify your overall rates for providing services. If you offer a sliding scale, please specify those rates as well.

Telehealth

Do you provide telehealth counseling services? We realize most do currently with the pandemic but will you continue with this option?

Insurance*

Do you take insurance? And if no, do you provide a superbill so that individuals can submit on their own?

Waiting List*

Please let us know if you currently have a waiting list.

Comments & Questions

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.