New Therapist Questionnaire Full Name Date of Birth Birth State Maiden Name (put N/A if none) Address Business Phone Number- Number given to client to contact you Personal Phone Number- For administration and clinical group Social Security Number W-4 or 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 Professional License- must be a copy of license given by LARA (PDF Format) NPI#- Individual CAQH# Liability Insurance Policy (PDF Format) Expiration Date for Liability Insurance Policy Are you in CHAMPS- State Medicaid System? Yes No With Which Insurances Are You Currently Credentialed? Professional Biography- for Web Site Professional Photo- for Web Site Banking Institution- for Direct Deposit Checking or Savings Account Checking Savings 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
