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*:  

Urgent referrals: Are you willing to accept urgent referrals?  


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.]

Adjustment disorder
Adoption specialist
Advanced or terminal illness
Anger management
Anorexia nervosa
Attachment disorders
Attention deficit disorders
Autism/pervasive development disorder
Bipolar disorder
Borderline personality disorder
Bulimia nervosa
Child abuse
Chronic illness
Chronic pain
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
Dementia Alzheimer's and others
Developmental delay
Dialectical behavioral therapy specialist
Disability evaluation
Dissociative disorder
Domestic violence
Dysthymic disorder
Eating disorder
Fertility disorder
Forensic sex offenders
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
Physical abuse/violence
Physically impaired patients
Police personnel
Post traumatic stress disorder (PTSD)
PTSD specialist
Pre-weight loss surgery evaluations
Psych disability evaluation management
Schizophrenia and other psychotic disorders
Sex offender
Sexual abuse/violence
Sexual dysfunction
Sleep disorders
Somatoform disorders
Stress management
Substance use disorders
Survivors of suicide
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