index
provider registration
 
Please fill out this form to register with us, and be sure to create your User Name and Password to return at a later point in time. Your account will be pending approval, so please be sure to include an email address for approval notification. Have further questions? Just send an email to: provider-registration@mhag.org.
 
Type: Individual   Organization
Title:
First Name:
Last Name:
Licensure & Degree Info:
ACSW BC-DMT BCPCC
Board Certified Addictionlogist CCMHC CCS
CCSW CNNC CSAC
DMFT DNP Ed.D.
IDADC LCAS LCAS-P
LCPC LCSW LMFT
LMHC LMSW LP
LPA LPC LPCA
LPL LPN LSW
M.Div M.Ed M.S.N.
MA MCHT MD
MPS MS MSC
MSSW MSW NCC
NP Other PA
Peer Support Specialist Ph.D. Psychiatric Clincial Nurse Specialist
Psychiatric MH Nurse Practioner PsyD R.N.
Active / Accepting Patients: Yes   No
Note: Selecting "No" will hide your information from public view.
User Name:
Password:
Practice Name:
Address:
City:
State:
Zip:
Phone:
Area Code: Phone Number: Ext.:
Separate Phone
for Appointments:
Area Code: Phone Number: Ext.:
Fax:
Area Code: Phone Number:
Website:
(Include full link)
Email:
Note: This is for internal use and password management only and will not be displayed to the public.

Gender of Provider:
Age Range of Provider:

Clientele Served:
Adolescents (11-17 year olds) Adults (18-65 years old) Children
Couples Families Seniors (65 years and older)
Veterans Veterans Families

Focus of Therapy:
Please fill these out or you will NOT appear in search results.
ADD/ADHD Aging Issues Anger Management
Anxiety Disorder Attachment Disorders Bipolar Disorder
Borderline Personality Disorder Cognitive Therapy Conduct Disorder
Cultural Issues Cutting Depression
Eating Disorders Education Employment Issues
Faith-based Family Gambling Addiction
Geriatrics GLBT Grief/Loss
Mental Health Recovery Mental Health Wellness Classes OCD
Other Parenting Pornography (Adult)
Pornography (Child) Post Partum Depression Psychiatric Inpatient Facilities
Psychiatric Outpatient Facilities/Programs PTSD Relationships
Residential Treatment - Group Homes Residential Treatment - Long Term Facilities Schizo-Affective Disorder
Schizophrenia Sexual Abuse Sexual Abusers
Sexual Addiction Sexuality Spirituality
Stress Women

Focus of Therapy/Substance Abuse:
Please fill these out or you will NOT appear in search results.
Prevention and Education Services Residential Treatment Residential Treatment - Half Way Houses
Substance Abuse - Alcohol Substance Abuse - Methadone Substance Abuse - Other
Substance Abuse - Prescription Drugs

Home Visit:
Emergency Service:
Prescribes Medicine:
Fluent in Spanish:
Case management:
Psychological Evaluations:

Payment/Fees:
Aetna Blue Cross Blue Shield Champus
Cigna Free - No Cost Humana
Medcost Medicaid Medicare
NC Health Choice No Insurance Other
Physicians Health Self Pay Sliding Fee Scale
State Employees Tri-Care United Health Care
 
Please state the circumstances under which you would consider accepting sliding scale or pro-bono:

 
Other:

Comments: