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*:

Urgent referrals: Are you willing to accept urgent referrals?
Yes No 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/terminal illness Agoraphobia Anger management Anorexia nervosa Attachment disorders Attention deficit disorders Autism/pervasive development disorder Bereavement/grief Bipolar disorder Borderline personality 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 (DBT) specialist Disability evaluation Dissociative disorder Divorce 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 LGBTQ+Affirming Learning disabilities Medication assisted treatment for opioid use disorder (for prescribers only) Medication assisted treatment for other substance use disorder (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 Visually impaired patients Women issues		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 Gender identity Generalized anxiety disorder Head injury patients Hearing impairment/hard of hearing HIV positive/AIDS patient LGBTQ+Affirming 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 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:
ABA Biofeedback Brief solution focused therapy Christian counseling Cognitive behavioral therapy/behavior modification Couples marriage therapy Dialectal/behavioral therapy Electro-convulsive therapy Existential phenomenological psychotherapy Family therapy Group psychotherapy Hypnosis Individual psychotherapy Medication management Narrative therapy Object relations theory based psychotherapy Play therapy Psychological testing		ABA Biofeedback Brief solution focused therapy Christian counseling Cognitive behavioral therapy/behavior modification Couples marriage therapy Dialectal/behavioral therapy Electro-convulsive therapy Existential phenomenological psychotherapy Family therapy Group psychotherapy Hypnosis Individual psychotherapy Medication management Narrative therapy Object relations theory based psychotherapy Play therapy Psychological testing

Behavioral Health Practitioner Areas of Clinical Focus Form

Form Instructions

Provider details:

Please enter the Provider contact information for this request:

Treatment age group:*

Primary area of clinical focus

Secondary area(s) of clinical focus

Primary modality

Secondary modality