Mental Health and Substance Abuse Resources and Providers - Mental Health Greensboro Drug Free Greensboro

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: