CULTURALLY CONNECTED CARE NETWORK Join Our Network Name(Required) First Last Professional Title(Required)Organization/Practice Nameif applicableEmail(Required) Phone(Required)(xxx) xxx-xxxAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Licenses/Certifications(Required)List all Licenses & Certifications. Include License Number and State of IssuanceYears of Experience(Required)Specializations(Required)What services are you interested in providing?(Required)Check all that apply Individual Therapy Group Therapy Family Therapy Workshops/Seminars Crisis Support Other Client Populations Served(Required)Check all that apply Children/Adolescents Adults Couples Families Groups BIPOC Communities LGBTQIA+ Communities Other Preferred Days of Service(Required)Check all that apply Monday Tuesday Wednesday Thursday Friday Saturday Sunday Preferred Times of Service(Required)Check all that apply Mornings Afternoons Evenings Why are you interested in partnering with our nonprofit?(Required)How do your services align with our mission?(Required)Are you currently credentialed with an insurance provider?(Required) Yes No If yes, please provide your ratesAre you willing to offer pro bono or sliding scale services?(Required) Yes No Do you require compensation for your services?(Required) Yes No If yes, please listDo you have any additional information or questions?I consent to have my information reviewed by the nonprofit for the purpose of evaluating my eligibility to become a provider.(Required) Yes No Type Your Full Name(Required)By typing your name below, you confirm submission of this form.Date MM slash DD slash YYYY
