Network Clinician Application
The Problem Gambling Help Network of West Virgina
Name
*
First Name
Last Name
Agency/Employer
*
Email
*
example@example.com
Personal Phone Number
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-
Area Code
Phone Number
Work Phone Number
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-
Area Code
Phone Number
Work Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Practice
*
Credentials (Degree, Professional License, Certifications)
West Virginia Credentials (Degree, Professional License, Certifications)
*
Are you generally able to schedule clients to be seen within 72 hours?
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Yes
No
Are you able to see clients via in-office, telehealth or both?
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In-Office
Telehealth
Both
Which of these insurance are you able to accept? (Note the PGHNWV pays in full for the initial assessment and will pay for those who do not have insurance.)
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Medicaid
Medicare
The Health Plan
Aetna
BCBS
Humana
United Health Care
Cigna
CareSource
Other
Why are you interested in becoming part of our network?
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Please upload a copy of your current mental health practice license:
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Cancel
of
I understand that 30+ hours of training is required to become part of the Problem Gambling Help Network of West Virginia. Future training dates are TBA. I understand that I or my employer must carry professional liability insurance for my practice. The number of treatment referrals is not guaranteed.
*
I agree
Signature
*
Submit
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