Registration: Regroup Therapy


* required field

Program Description
Program description (ex. Outpatient, inpatient or residential; availability of medically-trained staff, current behavioral health services, if any)

Services Needed
MD Hours
Do you accept residents (3 yr+)?
 Yes  No
Do you require board certification?
 Yes  No

Child/Adolescent MD Hours:
Do you accept fellows (1 yr+)?
 Yes  No
Do you require board certification? (C/A)
 Yes  No

APN Hours
Are there doctors on-site you prefer to serve as the collaborating physician?
 Yes  No

Non Prescriber Hours
Other notes on specialties (for therapists, theoretical orientation):

Do providers need to be credentialed with payors? If so, please describe. (ex. Medicare, Medicaid, managed care, private payors, etc.)
Any specific language needs?
Complete schedule of possible days/times that would work for staffing (including opening and closing hours if flexible)?
Other notes on clinical care expectations (ex. length of sessions, number/frequency of sessions, etc.):

We appreciate your time and interest

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