Secure Clinician Enrollment Form

Sent via secure email *

Welcome to Counseling Associates! We are pleased that you have decided to join our team.
Below you will find a list of required documents and information needed so that we may begin the process of credentialing.
Please submit the required documents to Lisa Tanguay, Operations Manager, at ltanguay@ca-mh.com and complete this secure online form by the date noted in your email.
Please understand we need to have all of these items in hand to complete the initial enrollment process for our malpractice insurance and then begin to apply for credentialing.

Please do not hesitate to contact Lisa Tanguay by phone: (603) 865-1321 x131 or email: ltanguay@ca-mh.com with any questions or concerns.

Required Documents*:
*Please submit all requested documents in PDF form. Insurance companies will not accept photos or text message formats.


  1. A clean copy of your graduate degree diploma(s)
  2. A copy of your current License Card(s) issued by the State of NH (LCMHC, LICSW, LADC, MLADC, LMFT, PhD, PsyD)
  3. Copy of your State of NH Board of Mental Health License. This document must include the original issue date of your license and the signatures of the Board of Mental Health Practice.
  4. An updated CV (please include the exact start and end dates for each job you held, as well as the address of the business you worked at (this information is needed for insurance companies))
 (* required info)
Your Name *
Address *
City *
State / Zip Code *  
SSN *
Date of Birth *
Birthplace * City and state where you were born.
Date Start Grad Progarm *
Graduation Date *
Degree(s) Attained *
Field of practice and title * LCMHC, psychologist, social worker, etc.
License Number * Mental Health license #
Number of years in practice *
Individual NPI# *
CAQH# * Please check with your current employer to see if you already have one.
If you don't we will create a CAQH account for you.
NH Medicaid# (if applicable)
Medicare# (if applicable)
Insurance Companies A list of any insurance companies that you have been credentialed with either currently or in the past.
 
  Clinical Specialties
Ages Served *
  • Toddlers (0-6)
  • Children (6-10)
  • Tweens (11-13)
  • Teens (14-19)
  • Adults
Sexuality Specialties *
  • Gay
  • Lesbian
  • Bisexual
 
  Issues & Specialties (from the categories below)
Specialty #1 *
Specialty #2 *
Specialty #3 *

Place a check in the box of up to 15 other issues you wish to highlight for your practice.

  • ADHD
  • Addiction
  • Adoption
  • Alcohol Abuse
  • Alzheimer's
  • Anger Management
  • Antisocial Personality
  • Anxiety
  • Asperger's Syndrome
  • Autism
  • Behavioral Issues
  • Bipolar Disorder
  • Borderline Personality
  • Career Counseling
  • Child or Adolescent
  • Chronic Impulsivity
  • Chronic Pain
  • Chronic Relapse
  • Codependency
  • Coping Skills
  • Depression
  • Developmental Disorders
  • Divorce
  • Domestic Abuse
  • Domestic Violence
  • Drug Abuse
  • Dual Diagnosis
  • Eating Disorders
  • Emotional Disturbance
  • Family Conflict
  • Gambling
  • Grief
  • Infertility
  • Infidelity
  • Intellectual Disability
  • Internet Addiction
  • Learning Disabilities
  • Life Coaching
  • Marital and Premarital
  • Men's Issues
  • Narcissistic Personality
  • Obesity
  • Obsessive-Compulsive (OCD)
  • Oppositional Defiance
  • Parenting
  • Peer Relationships
  • Pregnancy, Prenatal, Postpartum
  • Racial Identity
  • Relationship Issues
  • School Issues
  • Self Esteem
  • Self-Harming
  • Sex Therapy
  • Sexual Abuse
  • Sexual Addiction
  • Sleep or Insomnia
  • Spirituality
  • Sports Performance
  • Substance Abuse
  • Suicidal Ideation
  • Teen Violence
  • Testing and Evaluation
  • Transgender
  • Trauma and PTSD
  • Traumatic Brain Injury
  • Video Game Addiction
  • Weight Loss
  • Women's Issues

Treatment Modalities

  • Acceptance & Commitment (ACT)
  • Art Therapy
  • Attachment-based
  • Coaching
  • Cognitive Behavioral (CBT)
  • Culturally Sensitive
  • Dialectical (DBT)
  • EMDR
  • Eclectic
  • Emotionally Focused
  • Existential
  • Expressive Arts
  • Family / Marital
  • Family Systems
  • Feminist
  • Forensic Psychology
  • Gestalt
  • Gottman Method
  • Humanistic
  • Hypnotherapy
  • Imago
  • Integrative
  • Interpersonal
  • Intervention
  • Jungian
  • Mindfulness-based (MBCT)
  • Motivational Interviewing
  • Multicultural
  • Narrative
  • Neuro-Linguistic
  • Neurofeedback
  • Play Therapy
  • Psychoanalytic
  • Psychodynamic
  • Psych. Testing & Evaluation
  • Relational
  • Sand Play
  • Solution Focused Brief
  • Somatic
  • Transpersonal
  • Trauma Focused

Comments
 
 

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