Provider Listing in Mental Health Spectrum
Please answer the following questions. Responses will be used to generate listing in Mental Health Spectrum (Issue 4 - November 2021).
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1a. Which general professional category do you want to be listed under? You must be licensed or certified to practice under your selection. *
1b. If you checked Other to question 1a, please list your preferred general category that you would want to be listed under.  
2. Please type your name as you would like it to appear in the publication. For example: Doe, Jane E. or Doe, Jane or Doe, Jane Elizabeth.  All names will appear alphabetically by last name under the general professional category that you selected in question 1a. *
3. Please list your educational credentials with the appropriate abbreviation in the order you would like them to appear after your name. For example, Master of Science (MS) or Licensed Clinical Social Worker (LCSW) or Doctor of Psychology (PsyD). In the publication, your name will be listed as such: Doe, Jane E. | MSW, LCSW *
4. What is your provider telephone number? *
5. Do you have a web site link that you would like listed? If not, please type N/A. *
6. Select the areas where you have a physical practice location. *
Required
7. Please provide the corresponding zip codes for the physical locations identifed above. Please list your primary location first.
8. Please check the primary age group that you work with and would like listed. *
9. Please provide your top two specialties that you work with (you may include, population, therapy type, topic, etc.). For example, LGBTQ, PTSD, Faith-based, Veterans, or Eating Disorders. If no specialty, please type general. *
10a. What forms of payment will you accept (cash, sliding scale, all insurances, only Medicaid, etc.)? Please keep responses brief. *
10b. Please list any insurances you will NOT accept. If this does not apply, please put N/A. *
11. Which languages other than English do you provide services in?
11a. If you provide services in any other language not listed above, please indicated below.
12. Which issue(s) are you listing for? *
Thank you.
Invoices will be sent upon receipt of your completed survey. If you have any questions, please contact Jacqui Ragin at publisher@mhrmedia.com or call (702) 336-8695.
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