CPS Mental Health Provider Directory

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If you are interested in appearing in the CPS Mental Health Provider Directory, please complete the following information below. If submitting for multiple providers, please complete a separate form for each provider.

Last Name *

First Name *

Credentials *

Organization

Address *

Phone Number *

Website

Please indicate youngest age client you would feel comfortable serving *

Please indicate oldest age client you would feel comfortable serving *

Hours *

Morning

Afternoon

Evening

Weekend

Required

Insurance accepted *

Private insurance

Medicaid

Medicare

Sliding Scale

Self Pay

Required

Services you provide: *

Check all that apply

Individual therapy

Group therapy

Family therapy

Required

Specialty Areas (list top 5 only) *

Other information you would like included:

Submit

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This form was created inside of Columbia Public Schools. Report Abuse

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