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Provider Registration Form

Please complete this form as accurately and completely as possible. Your responses will help us ensure that our directory is complete and up to date, and your feedback will ensure that the site serves its intended audience... mental health providers in the Roaring Fork Valley and those looking for help with mental health issues for themselves, friends or loved ones.

We reserve the right to review submitted information for accuracy and may request follow-up information or clarification at our discretion.

Contact Information

The information provided in this section WILL NOT appear in the directory. We will use this contact to verify directory information and for future information updates.

Enter the email address for verification and communication about this listing. This email address will NOT be shown in the directory.

This number WILL NOT be listed in the public directory.

Practice Information

Please provide the business name under which you operate.

Enter the public email address (if any) that should be used to contact your organization. THIS EMAIL ADDRESS WILL BE SHOWN TO THE PUBLIC. If you are restricted by HIPPA or other requirements that forbid the use of email, DO NOT ENTER AN EMAIL ADDRESS HERE.

Please enter the public phone number (if any) to be included on your listing.

Please enter the URL for your public website. This URL will be provided as a link with your listing in the directory.

Please provide a brief description or bio for your practice. This text will be displayed as a description on your listing. Please limit your bio to 150 words or less.

The directory lists mental health service providers serving the communities from Aspen to Rifle.

Credentials

Please provide a detailed description of the credentials that you or your organization hold. Use the "Other Credentials" box to descibe items that may not be listed here.

Are you registered with the state of Colorado (DORA)?

Please provide details of relevant licenses and/or certifications held by you and/or professional staff. Examples are "Licensed Clinical Social Worker (LCSW)", "Marriage & Family Therapist (MFT)", "Licensed Professional Counselor (LPC)", "Certified Addictions Counselor (CACIII)", etc.

Select all relevant degrees held in your organization and explain the relevance below.

Please use this area to briefly describe the relevance of your degrees (i.e. what fields are the degrees in).

Please provide relevant C.V.

Please provide any additional relevant credential or licensing information not described above.

Service Details
Hours of Operation

Please provide daily hours of operation for the days when you are regularly open (eg. 8am - 5pm), or enter "By appt" for days by appointment.

Enter any additional information pertaining to hours of operation.

Mark all areas of expertise that apply. You may use the "Expertise Details" section below to provide additional details.

Enter any additional information pertaining o your areas of expertise in mental health.

If you offer services in chemical dependence, please check all that apply.

Please select the types of therapy offered. Use the "Therapy Details" section below to provide any additional details.

Enter any additional information pertaining to therapies offered.

Mark all populations that apply. You may use the "Population Details" section below to provide additional details.

Enter any additional information pertaining to populations served.

Insurance and Payments

Do you as an individual provider or does your organization accept insurance? If yes, please describe below.

If you answered Yes above, please provide details of insurance plans that you work with.

Do you offer services on a sliding scale?

Please provide any additional information that you would like clients to know about your payment policies and options.

We Need Your Help

This website will be a success if it serves it's audience, the valley's mental health and social service providers and the people who depend on their services, but may not know where to turn. Please give us feedback to help direct the future development of this site.

Please list up to 3 features that you would find helpful for you or your clients when dealing with mental health issues?

If we were to provide a directory of links to other resources relevant to mental health issues in the community, what websites would you recommend that we list and why?

This site can use the support of valley mental health professionals in promoting the site, managing and reviewing listings and other site information, and in the form of financial support for awareness campaigns and site maintenance.

Please describe other ways that you can help us make this site a great community resource.

If you have a website, what tools or features have your users found most helpful? Are there vital resources that you would like to provide online but have been unable to?

Thank you for taking the time to be a part of this new community resource. We appreciate your involvement and hope that you will forward the link to this form to other mental health professionals. We aim to provide a comprehensive resource for the valley.

Please sumbit the form below to complete your registration.

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