Healing TREE (Trauma Resources, Education & Empowerment)


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!
First Name: *
Middle Initial:
Last Name: *
Post-Nominal (eg: LCSW, PhD): *
Gender *
Pronouns
What type of provider are you? *
Company Name (if applicable):
Email: *
Website Address: *
Business Street Address: *
Business City: *
Business State: *
Business ZIP Code: *
Business Phone: *
Fax:
Business 2 Street Address:
Business 2 City:
Business 2 State:
Business 2 ZIP Code:
Business 2 Phone:
Please provide the bio you would like displayed on our website, should you become a part of our network: (Please provide in 3rd person; 1024 character limit) *
Year Practice Began: *
Age Group Treated: *	Ages 11 and under Ages 12 - 17 Ages 18 and older All ages
LGBTQIA+ Friendly / Affirming: *
Language(s) Spoken: *
Describe your emergency protocol: *
Type of Insurance Accepted: *	Medicare/Medicaid Out of Network Accepts Insurance Private Pay Only
List of Insurances Accepted: (Please type "N/A" if none) *
Please check the type of training you have received. **Please note that these are the training certificates you will need to submit to us to complete your application.	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
If you selected OTHER - including CEUs above, please describe: (1024 characters)
Are you certified as a faith-based counselor? Please type "Yes" or "No" and if "Yes," please explain. ***Please note that you will need to send us your certificate to complete your application.
Please check the type of supplemental care training you have received. **Please note that these are the training certificates you will need to submit to us to complete your application.	Acupuncture Art Therapy Drama Therapy Music Therapy Expressive Arts Therapy Equine-Assisted Therapy Trauma-Sensitive Yoga Other (Please describe below) Not Applicable
If you selected OTHER above, please describe: (1024 characters)
Please list forms of abuse suffered you have treated successfully: (e.g. Abandonment, Abuse of Power (Teacher, Law Enforcement, Clergy, etc.), Betrayal, Bullying, Cultic (Group or One-on-One), Developmental Trauma, Emotional, Financial, Neglect, Psychological, Sexual, Spiritual/Religious, Verbal) *
Please list other forms of trauma you have treated successfully (e.g. Accidents, Having a loved one who is an addict, Illnesses, Natural Disasters, War) *
Please list conditions you have treated successfully - patient no longer has diagnosis (e.g. Addictions, Anxiety Disorders, Bipolar Disorder, Borderline Personality Disorder (BPD), Complex Post-Traumatic Stress Disorder (C-PTSD), Depression, Dissociative Identity Disorder (DID), Eating Disorders, Post-Traumatic Stress Disorder (PTSD), Psychogenic Non-Epileptic Seizures (PNES), Trauma-related pain conditions) *
Please let us know anything else that you feel we should know in regards to your practice as it relates to treating trauma. (1024 character limit) *
Please list authors who have influenced your practice: *
Where did you receive your training? (1024 character limit) *
Provide License Type, Number and State: *
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.
Provider info on site *	Age group treated Bio Business Address Email Insurances accepted Language(s) spoken LGBTQIA+ Friendly / Affirming Phone Number Treatment modalities Website
How did you learn about Healing TREE? (limit 1024 characters) *

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