Registration: Regroup Therapy

If you have not yet registered for access to our online scheduling system, please complete the following form.

* required field
APPLICANT INFORMATION
 

Specialties/Interests
* Adults
Experience
Interest
* Are you board certified to work with adults?
 Yes  No
Adults: If no, date of board certification exam

* Child/Adolescents
Experience
Interest
* Are you board certified to work with child/adolescents?
 Yes  No
Child/Adolescents: If no, date of board exam

* Addictions
Experience
Interest
* Are you board certified to work with addictions?
 Yes  No
Addictions: If no, date of board certification exam

* Developmental Disability/Autism Spectrum
Experience
Intrest

* Corrections
Experience
Interest

* Serious/Chronic Mental Illness
Experience
Interest

* Older Adults
Experience
Interest

* Inpatient/Residential
Experience
Interest

License Information
* Licensed in State(s)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* License(s)
MD
APN
PA
Psychiatry Resident (independently licensed)
LCSW
LCPC/LMFT
LSW (trainee)
License Notes

Credentialing/Payer Information
* Medicare
 Yes  No
* Medicaid
 Yes  No
* Private Payers
 Yes  No
Credentialing/Payer Preferences Notes

Fluent Languages
ASL (Sign Language)
Arabic
Chinese
Dutch
Farsi
Finnish
French
German
Greek
Hebrew
Hmong
Indian (Hindi/Urdu/Misc)
Italian
Japanese
Polish
Portugese
Russian
Spanish
Somali
Swedish
Tagalog
Thai
Vietnamese
Other
Multi-Language Notes
Other preferences
* Interested in supervision of psychiatry residents?
Yes
No
Maybe
* Interested in being a collaborative physician for APNs?
Yes
No
Maybe
* Total max hours desired at this time:
Hour Notes



Thank you for your interest!
 
 
Chicago, Illinois 60640
860-539-9019
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