Provider Interest Form

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We are thrilled that you are considering joining The Willow Collective!
We are a network of private practice providers in the field of maternal, infant, and early childhood mental health. Our goal is to build our community’s capacity to meet the needs of young children and their families.

Your name *

Name of your LLC (*note: members must have their own LLC and malpractice insurance to join) *

Malpractice insurance policy number *

Degree and/or license *

Your business email address

Your business phone number

Your business address

Your business website

Please list any languages you speak, other than English:

Payment forms you accept:

Private pay

Sliding fee scale

Medicaid

Private insurance (please list under "other")

HSA/FSA

Victims compensation

Other:

Areas of specialty: *

Maternal mental health / pregnancy / postpartum

Infant mental health (ages 0-2)

Early childhood mental health (ages 2-8)

Parent-child / family

Individual adults

Couples

Addictions / substance abuse

Grief / loss

Other:

Required

Modalities that you offer/use: *

Child-Parent Psychotherapy

Parent-Child Interaction Therapy

Trauma-Focused Cognitive Behavioral Therapy

Play therapy

Applied behavior analysis / behavior therapy

Theraplay

Circle of Security

EMDR

Neurofeedback

Dialectical behavior therapy

Cognitive behavior therapy

Internal family systems

Motivational interviewing

Art therapy

Music therapy

Mindfulness

Yoga

Psychiatry / medication management

Group therapy (please describe under "other")

Support group(s) (please describe under "other")

Other:

Required

Please tell us about your interest in joining the Willow Collective:

Anything else we should know?

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