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Headstrong Clinical Partner
Qualifying Questions
*Are you fully licensed to practice independently?
Please select...
Yes
No
*Do you regularly use standardized assessments to track progress?
Please select...
Yes
No
Sometimes
*Are you trained in and utilize at least one of the following EBPs for PTSD: CPT, EMDR, PE?
Please select...
Yes
No
*Do you have the availability for 2-3 clients in the first month following onboarding?
Please select...
Yes
No
*Do you have experience working with military/veterans or first responders?
Please select...
Yes
No
*What is your practice address?
Street Address
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Basic Information
Ex: MD, PhD, PsyD, LCSW, LMFT, LPC
*Military service
Please select...
Yes
No
*State License(s)
Please select...
PSYPACT
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Select all that apply. Use Ctrl function to make multiple selection
Non-English Languages spoken
Please select...
Spanish
Chinese (including multiple varieties)
Tagalog
Vietnamese
French
Arabic
Other
Select all that apply. Use Ctrl function to make multiple selection
Application
*How did you hear about Headstrong? Please include whether you have colleagues who are current/prior Headstrong Clinical Partners.
*What draws you to become a Headstrong Clinical Partner?
*Describe your experience working with a military and/or veteran population.
*Describe your clinical orientatio
n.
*List your preferred population(s) including age considerations as well as cultural diversity
.
*Do you have populations you do not work with?
*List what evidence-based
PTSD
therapies you use in your practice.
Please select...
CPT
EMDR
PE
Select all that apply. Use Ctrl function to make multiple selection
*List your clinical specialties
*Do you work with couples?
Please select...
Yes
No
*Do you work with substance use?
Please select...
Yes
No
*Do you do neurofeedback
?
Please select...
Yes
No
*Telehealth
Please select...
Telehealth-only
In person
Both
*Describe your clinical practice operations including: practice setting, record keeping approach, and scheduling procedures.
*What are your regular hours of operations?
Upload your CV
Upload CV acceptable file types: MS Doc and PDF
Contact Information
New Form Area
Headstrong Clinical Partner
Qualifying Questions
*Are you fully licensed to practice
independently?
Please select…
Yes
No
*Do you regularly use standardized assessments to
track progress?
Please select…
Yes
No
Sometimes
*Are you trained in and utilize at least one of
the following EBPs for PTSD: CPT, EMDR, PE?
Please select…
Yes
No
*Do you have the availability for 2-3 clients in
the first month following onboarding?
Please select…
Yes
No
*Do you have experience working with military/veterans
or first responders?
Please select…
Yes
No
*What is your practice address?
Street Address
City
State
Please select…
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Basic Information
Ex: MD, PhD, PsyD, LCSW, LMFT, LPC
*Military
service
Please select…
Yes
No
*State
License(s)
Please select…
PSYPACT
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Select all that apply. Use Ctrl function to make multiple selection
Non-English
Languages spoken
Please select…
Spanish
Chinese (including multiple varieties)
Tagalog
Vietnamese
French
Arabic
Other
Select all that apply. Use Ctrl function to make multiple selection
Application
*How did you hear about Headstrong? Please include whether you have colleagues
who are current/prior Headstrong Clinical Partners.
*What draws you to become a Headstrong Clinical
Partner?
*Describe your experience working with a military
and/or veteran population.
*Describe your clinical orientatio
n.
*List your preferred population(s) including age
considerations as well as cultural diversity
.
*Do you have populations you do not work with?
*List what evidence-based
PTSD
therapies you use in your practice.
Please select…
CPT
EMDR
PE
Select all that apply. Use Ctrl function to make multiple selection
*List your clinical specialties
*Do you work with couples?
Please select…
Yes
No
*Do you work with substance use?
Please select…
Yes
No
*Do you do neurofeedback
?
Please select…
Yes
No
*Telehealth
Please select…
Telehealth-only
In person
Both
*Describe your clinical practice operations including: practice setting, record keeping approach, and scheduling procedures.
*What are your regular hours of operations?
Upload your CV
Upload CV acceptable file types: MS Doc and PDF
Contact Information