Approved Care Network (Treatment Facility) 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 your facility's logo (in 300px by 300px or greater to display clearly on our site) ready as you will need to email it after you submit this form. Once you submit, you will be emailed a link to send the file.
Once your application is received, it will be reviewed for approval and you will be contacted to discuss your application further. If you are approved for our ACN, your logo 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!
Name of Facility *
Primary Location Street Address: *
City: *
State: *
Alabama - AL Alaska - AK Arizona - AZ Arkansas - AK California - CA Colorado - CO Connecticut- CT District of Columbia - DC Delaware - DE Florida - FL Georgia - GA Hawaii - HI Idaho - ID Illinois- IL Indiana - IN Iowa - IA Kansas - KS Kentucky - KY Louisiana - LA Maine - ME Maryland - MD Massachusetts - MA Michigan - MI Minnesota - MN Mississippi - MS Missouri - MO Montana - MT Nebraska - NE Nevada - NV New Hampshire - NH New Jersey - NJ New Mexico New York - NY North Carolina - NC North Dakota - ND Ohio - OH Oklahoma - OK Oregon - OR Pennsylvania - PA Puerto Rico - PR Rhode Island - RI South Carolina - SC South Dakota - SD Tennessee - TN Texas - TX Utah - UT Vermont - VT Virginia - VA Washington - WA West Virginia - WV Wisconsin - WI Wyoming - WY
ZIP Code: *
Primary Phone: *
Website *
Email: *
Admissions Coordinator Name: *
Admissions Coordinator Direct Phone Number:
Age Group Treated: *
Ages 11 and under
Ages 12 - 17
Ages 18 and older
All ages
Do you offer inpatient and/or outpatient options? *
Inpatient Only
Outpatient Only
Both Inpatient and Outpatient
Gender of Population Served: *
Female
Male
Transgender and Non-binary
LGBTQIA+ Friendly / Affirming *
Yes No
Language(s) Spoken by key Staff: *
Admission Criteria: (1024 character limit) *
Type of Pay Accepted: *
Private Pay Only
Nonprofit - No cost
Scholarships Available
Insurance Accepted
List of Insurances Accpeted
Please provide the bio of your facility that you would like displayed on our website, should you become a part of our network: (Please provide in 3rd person; 1024 character limit) * *
Types of Therapy Provided: *
Individual Therapy
Group Therapy
Supplemental Therapy (Trauma-Sensitive Yoga, Equine Assisted Therapy, Art Therapy, Drama Therapy, Music Therapy, Expressive Arts Therapy etc.)
Classes Provided
Referral Service Options For Ongoing Therapy
Types of treatment modalities used in individual therapy sessions: (e.g. Brainspotting, Eye Movement Desensitization & Reprocessing (EMDR), Mindfulness Informed Interventions, Sensorimotor Psychotherapy, Somatic Experiencing) *
Types of Supplemental Care available (e.g. Trauma-Sensitive Yoga, Equine Assisted Therapy, Dance Therapy, Music Therapy, Drama Therapy, Expressive Arts Therapy): (1024 character limit) *
Please list the types of mental health professionals that are available onsite (e.g. social worker, psychiatrist, psychologist): (1024 character limit) *
Is your facility prepared to handle clients exhibiting suicide ideation? *
Yes
No
Is your facility prepared to handle clients exhibiting eating disorders? *
Yes
No
Is your facility prepared to handle clients with active addiction(s)? *
Yes
No
If you checked "YES" to any of the previous three questions, please explain: (1024 character limit)
Do your clients have access to phones and/or an "open door" policy? Please explain: (1024 character limit) *
Are there mental illnesses and conditions your facility is NOT able to treat? Please list and describe: (1024 character limit) *
Please list any other information you would like to share about your facility as it relates to healing trauma: *
Select the information you will allow us to include on our website: *
Age group treated
Bio of facility
Language(s) Spoken
LGBTQIA+ Friendly / Affirming
Name and contact information of Admissions Coordinator
Address, email, phone number and website of facility
Specific admissions criteria
Types of pay accepted
Types of treatment modalities available
Please list any credentials information required by your state: (1024 character limit) *
How did you learn about Healing TREE? (limit 1024 characters) *
Agreements & Submission
All fields marked with an * are required.
I certify that I have the authorization to submit this information and understand that Healing TREE will be verifying all of our information for accuracy, and that I have read and agreed to the following information on behalf of our facility:
a. If and once approved for their network, I realize it is our responsibility to notify Healing TREE within 30 days should our name, address, or status change.
b. In the rare instance that a client requests that a team member of Healing TREE discuss their progress with us, I understand that we 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 Healing TREE's Approved Care Network, we agree to keep record of the clients that find our facility 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 the facility and providers there alone are responsible for their care and practice. I also understand that Healing TREE has the right to remove our facility 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