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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: email@example.com
We thank you again for your interest in joining our network and for the very important work that you do!
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: firstname.lastname@example.org
Together we can transform how society responds to abuse and interpersonal trauma.