Behavioral Health Practitioner Areas of Clinical Focus Form

Form Instructions

Fields marked with an asterisk (*) are required fields.

This form should not be used to make updates to your practice (address, phone, email, or availability), please use the Provider Information Update Form.

Effective date:*  
Effective date of change:* [mm/dd/yyyy]  

Provider details

Please enter the Provider contact information for this request:

Provider last name:*  
Provider first name:*  
NPI number:*  
Email address:*  

Urgent referrals: Are you willing to accept urgent referrals?


Accepting urgent referrals means that you agree to be in contact with the member to schedule an appointment within 24 hours and agree to see the member face-to-face within 72 hours.

 

Treatment age group:*

   
Children 0-12    
Adolescents 13-18    
Adults 19-64    
Geriatric 65+    

Primary area of clinical focus

Secondary area(s) of clinical focus

From the categories listed below, select your primary area of clinical focus:

Check only the area(s) of clinical focus for which you would accept a referral: [Note: Area(s) of clinical focus will be listed in the provider directory.]













































































ABA
Adjustment disorder
Adoption
Adoption specialist
Advanced or terminal illness
Agoraphobia
Anger management
Anorexia nervosa
Attachment disorders
Attention deficit disorders
Autism/pervasive development disorder
Bereavement/grief
Bipolar disorder
Borderline personality disorder
Bulimia nervosa
Child abuse
Chronic illness
Chronic pain
Co-dependency
Co-occurring medical problems/pain management
Co-occurring mental health and substance use disorder
Compulsive gambling
Conduct disorder
Crisis intervention services
Critical incident debriefing
Cyclothymic disorder
Delirium
Dementia Alzheimer's and others
Depression
Developmental delay
Dialectical behavioral therapy specialist
Disability evaluation
Dissociative disorder
Divorce
Domestic violence
Dysthymic disorder
Eating disorder
Fertility disorder
Forensic sex offenders
Gay/lesbian/bisexual
Gender identity
Generalized anxiety disorder
Head injury patients
Hearing impairment/hard of hearing
HIV positive/AIDS patient
Learning disabilities
Medication assisted treatment for opioid use disorder (for prescribers only)
Medication assisted treatment for other substance use disorders (for prescribers only)
Military sexual trauma
Neuro-psych testing
Obsessive compulsive disorder
Oppositional defiant disorder
Panic disorder
Parenting skills
Pastoral counseling
Personality disorder
Phobias
Physical abuse/violence
Physically impaired patients
Police personnel
Post traumatic stress disorder (PTSD)
PTSD specialist
Pre-weight loss surgery evaluations
Psych disability evaluation management
Psychosomatic
Schizophrenia and other psychotic disorders
Sex offender
Sexual abuse/violence
Sexual dysfunction
Sleep disorders
Somatoform disorders
Stress management
Substance use disorders
Survivors of suicide
Transgender
Visually impaired patients
Women issues


Primary modality

Secondary modality

Select your primary modality:

Check only the secondary modality for which you would accept a referral:






















Cognitive behavioral therapy/behavior modification






Hypnosis