Staff Form – Provider Interest – Revive Center for Wellness

First Name *

Last Name *

Phone Number *

Email Address *

Sex *

Date of Birth *

Address *

Address

City

State/Province

Zip/Postal

Languages (Conversational)

States of Licensure (Select all that Apply)

License Numbers and States of Issuance

NPI #

CAQH #

Experienced supervisor? *

Interested in leadership or supervisor role? *

Currently engaged in private practice? *

If yes, how many existing clients?

# Weekly sessions desired? *

In-network with any insurance? *

If Yes, which Insurance Carriers and States

Interested in offering telehealth? *

Availability to see clients *

Reason for Interest in Revive (Select all that Apply) *

Need for Office Space

Need for Payment/Billing/Invoice Services

Need for Referrals and/or Marketing Services

Need for Supervision/License Hours

Desire to be part of a Community

Other (Please specify in comments below)

How did you learn about Revive? *

Why would you like to join Revive?

How will this position fit in with your long-term goals?

What would you like us to know about you?

Please provide any additional information:

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