Approved Care Network (Individual Mental Health Professional/ Supplemental Care Provider) Application

All fields marked with an * are required.

Thank you for your interest in joining our Approved Care Network (ACN). Before beginning this application, please have a copy/ photo of your license, training certificates, and headshot (in 300px by 300px or greater to display clearly on our site) ready as you will need to email them after you submit this form. Once you submit, you will be emailed a link to send the files.

Once your application and documents are received, they will be reviewed for approval and you will be contacted to discuss your application further. If you are approved for our ACN, your training certificates and license will be kept in your file within our system and your headshot will be used to display on our site.

Please know that we will be happy to update or remove any of your information if necessary if you contact us via the email below.

For any questions or concerns, please contact our Approved Care Network Team at: acn@healingtreenonprofit.org

We thank you again for your interest in joining our network and for the very important work that you do!

Ages 11 and under
Ages 12 - 17
Ages 18 and older
All ages
Medicare/Medicaid
Out of Network
Accepts Insurance
Private Pay Only
Acceptance and Commitment Therapy (ACT)
Brainspotting - Phase 1
Brainspotting - Phase 2
Brainspotting - Intensive
Brainspotting - Certified Practitioner
Brainspotting - Advanced/Specialty Training
Dialectical Behavior Therapy (DBT)
Eye Movement Desensitization & Reprocessing (EMDR) - Part 1
Eye Movement Desensitization & Reprocessing (EMDR) - Part 2
Eye Movement Desensitization & Reprocessing (EMDR) - Part 1 & 2
EMDRIA Approved Consultant or Trainer
EMDRIA Approved Training Provider/HAP Trainer
Mindfulness Based Cognitive Therapy (MBCBT)
Mindfulness Based Relapse Prevention Therapy (MBRPT)
Sensorimotor Psychotherapy - Level 1
Sensorimotor Psychotherapy - Level 2
Sensorimotor Psychotherapy - Level 3
Sensorimotor Psychotherapy - Certified Advanced Practitioner
Somatic Experiencing - SE Practitioner
Trauma training certificate (International Association of Trauma Treatment Professionals or other reputable organization)
Other - including CEUs (Please describe below)
None of the Above
Acupuncture
Art Therapy
Drama Therapy
Music Therapy
Expressive Arts Therapy
Equine-Assisted Therapy
Trauma-Sensitive Yoga
Other (Please describe below)
Not Applicable

I understand that Healing TREE will be verifying all of my information for accuracy, and that I have read and agreed to the following:

a. If and once approved for their network, I realize it is my responsibility to notify Healing TREE within 30 days should my address or status change.

b. In the rare instance that a client requests that a team member of Healing TREE discuss their progress with me, as their mental health and/or supplemental care professional, I understand that I must obtain a signed request from the client directly and that copy of this request will be emailed to Healing TREE to also keep on file.

c. If approved for either or both the Approved Care Network or the Approved Supplemental Care Network, I agree to keep record of the clients that find my practice through Healing TREE and will make that information available to Healing TREE in aggregate form (such as total counts, types of issues dealt with) whenever requested. (Note: Healing TREE will never request PHI for an individual client.) I acknowledge that I alone am responsible for my care and practice. I also understand that Healing TREE has the right to remove me from their website at any time.

We will notify you shorty regarding the status of your application. Should you have any questions, please contact our Approved Care Network Team, at: acn@healingtreenonprofit.org

Together we can transform how society responds to abuse and interpersonal trauma.  

 

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