Prospective Therapist Questionnaire Full Name Email Credentials-State License Type, Certifications Up-to-Date Resume Are there any complaints against your license? No Yes If yes, please explain Have you ever been convicted of a misdemeanor or felony? No Yes If yes, please explain Desired Sessions Per Week? 8-12 13-16 17-24 25-28 29+ How much in-person therapy are you interested in performing? 25% 50% 75% 100% What age group(s) would you like to work with? Infant/Toddler Child Adolescent Young Adult Middle-Age Adult Senior Citizen What age group(s) would you like to work with? Infant/Toddler Child Adolescent Young Adult Middle-Age Adult Senior Citizen What type of presenting issues would you like to work with? Depression/Anxiety Trauma Family Couple/Relationship Child/Adolescent Behavior Medical Adjustment Substance Abuse Adult Behavior- Gambling, Shopping, Eating, etc. Sexual LGBTQ+ Personality Disorders Psychosis Other (Explain below) If other, please explain Please provide a sample progress note- redact any name or identifying information if using an actual progress note from your past. Signature (Please type full name) Date Send New Therapist Questionnaire Full Name Date of Birth Birth State Address Business Phone Number- Number given to client to contact you Social Security Number W-9- PDF format Professional Service Agreement- Signed, PDF format State License Type Graduation Date for Master’s Degree Institution for Master’s Degree State Professional License Number Expiration Date for State Professional License NPI#- Individual CAQH# Liability Insurance Policy- PDF format Expiration Date for Liability Insurance Policy Are you in CHAMPS- State Medicaid System? Yes No Professional Biography- for Web Site Professional Photo- for Web Site Banking Institution- for Direct Deposit Routing Number for Direct Deposit Account Number- for Direct Deposit Days/Times would you like to work Monday 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm Tuesday 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm Wednesday 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm Thursday 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm Friday 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm Saturday 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm Sunday 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm How much of your caseload would you like to be telehealth? 0% 25% 50% 75% 100% Signature (Please type full name) Date Send Daily Service Log Date Entry 1 Name CPT Code Place of Service 11-Office, 12-Tele Entry 2 Name CPT Code Place of Service 11-Office, 12-Tele Entry 3 Name CPT Code Place of Service 11-Office, 12-Tele Entry 4 Name CPT Code Place of Service 11-Office, 12-Tele Entry 5 Name CPT Code Place of Service 11-Office, 12-Tele Entry 6 Name CPT Code Place of Service 11-Office, 12-Tele Entry 7 Name CPT Code Place of Service 11-Office, 12-Tele Entry 8 Name CPT Code Place of Service 11-Office, 12-Tele Sign Name By signing this form, you are certifying that you the specified services have been performed within the specifications of the given billing code AND all of the paperwork for the services has been completed (Treatment Plan must be completed by the end of the 2nd Session) Send
