Catholic Counselor Provider Application

Step 1 of 5 - Counselor Application

20%

Email(Required)

Enter Email Confirm Email

Type of Application(Required)

Referral List

Archdiocese Website

Both

Personal Information

Name(Required)

First Last

Tax ID or SSN #:(Required)

Address(es):(Required)

Phone:(Required)

Fax #:(Required)

Answering Service:

Email:(Required)

Website:(Required)

Do you have a receptionist or secretary?(Required)

Yes

Malpractice Carrier and Policy Number:(Required)

Parish you attend:(Required)

Languages:(Required)

English

Spanish

Sign

Other

POPULATIONS SERVED

Check all that apply:(Required)

Infant and toddler (6 months - 4 years)

Children and adolescents (5 - 17)

Adults (18 - 65)

Senior adults (66 and up)

Service Modalities:(Required)

Individual

Group

Couple/Marriage

Family

AREAS OF SPECIALIZATION

Addictions:(Required)

Alcohol/Substance Abuse

Gambling

Pornography

Sexual

Specializations:(Required)

ADD/ADHD

Anxiety/Panic Attacks

Behavior Modification

Chronic Pain/Illness

Death/Dying

Depression

Domestic Violence

Family

Grief Counseling

Parenting

Pervasive Developmental Disorder

Severe and Persistent Mental Illness (bipolar disorder, schizophrenia)

Sexual Abuse/Violence

INSURANCE PANELS

Check insurance panels for which you are a current in-network provider:(Required)

Aetna

BCBS of Kansas

BCBS of Kansas City

Cigna

Coventry

First Health

GEHA

Humana

Mail Handlers

Medicare

MHNet

Tricare

United Health Casre

Value Options

Others

Is there anything else about your practice that you think we should be aware of ?

After submitting this form, please send professional vitae by U.S. Mail

12615 Parallel Parkway
Kansas City, KS 66109

or email: famlife@archkck.org

Phone

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Counselor Application for Catholic Referral

Personal Information

POPULATIONS SERVED

AREAS OF SPECIALIZATION

INSURANCE PANELS