Telehealth Therapist Onboarding Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Professional License Number and State of Issuance

Highest Degree Earned (e.g., PhD, PsyD, LCSW, LMFT)

Please upload a copy of your professional license or certification

Years of Clinical Experience

Select your areas of clinical expertise

Are you comfortable using secure video conferencing tools for therapy sessions?

Please list your typical weekly availability for telehealth sessions (days and times)

Emergency Contact Name and Phone Number

Signature (please sign below to confirm your consent and agreement)