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New Associate Application
Psychological Behavioral Health Inc.
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* Indicates required question
Email
*
Your email
Request affiliation with Psychological Behavioral Health (PBH):
*
Associate Volunteer. Already connected to employer/supervisor.
Associate Volunteer. I am interested in finding an employer/supervisor.
Other:
Required
First name
*
Your answer
Middle Name
*
Your answer
Last Name
*
Your answer
Phone number
*
Your answer
License type?
*
AMFT
ACSW
ASW
APCC
Psychological Associate
Other:
Associate license number?
*
Your answer
Associate license start date?
*
MM
/
DD
/
YYYY
Associate license expiration date?
*
MM
/
DD
/
YYYY
Individual NPI number?
*
Your answer
Is the associate license linked to California?
*
Yes
No
Not applicable
Other:
Associate current place of employment?
*
Your answer
Able to offer services in a second language?
*
Yes
No
Maybe
Second language or type NA?
*
Your answer
Name of employer?
*
Your answer
Name of supervisor?
*
Your answer
How many clinical hours remain to complete the board requirements?
*
Your answer
Areas of interest?
*
Your answer
Services to be offered:
*
In-Person
Telehealth
Both In-Person and Telehealth
Unsure
CAQH number?
*
Yes
No
Unsure
Not applicable
CAQH Number or type N/A
Your answer
How did you first learn about Psychological Behavioral Health?
*
Internet
Indeed or zip recruiter or other similar business.
I was referred by a current clinician affiliated with Psychological Behavioral Health.
I was referred by a clinician NOT affiliated with Psychological Behavioral Health Inc.
Psychological Behavioral Health website
Referred by other associate
Other:
Required
(For Employer) Associate practice address?
Your answer
(For Employer) Associate claims will be linked to which carriers?
Carelon (Medi-Cal)
MHN
Cigna
Anthem Blue Cross
Optum/United Healthcare
Medicare
Other:
(For Employer) What associate email address do you want to register with PBH?
Your answer
(For Employer) Add associate to group email?
Yes
No
Clear selection
If you were referred by a current clinician, what is the name of the clinician (or type not applicable)?
*
Your answer
Additional Comment
Your answer
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