Submit Your Onboarding Documents!Submit Your Onboarding Documents and our Changing Minds Administrator contact you to started! Name * First Name Last Name Date of Birth [MM-DD-YYYY] * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Licensure Type * Licensed Clinical Social Worker Licensed Marriage and Family Therapist Licensed Clinical Professional Counselor Licensed Drug and Alcohol Counselor Clinical Social Work Intern Marriage and Family Therapist Intern Clinical Professional Counselor Intern Drug and Alcohol Counselor Intern NV State License Number * If you haven't been issued a license state why Contact Information for Primary Supervisors/Clinical Supervisor * First Name, Last Name, Credentials, Phone Number and Email Address of each. If not applicable, write NA NPI Number * Are you currently credentialed with Medicaid of Nevada? * Are you currently sanctioned by Medicaid? * If you are currently sanctioned by Medicaid we are unable to contract with you at that this time. Yes No Upload Documents Below CAQH Registration ID# * If you haven't done it already, complete at https://proview.caqh.org/Login/Index?ReturnUrl=%2f CAQH Login * CAQH Password * Our Changing Minds Credentialing has received your documents and will contact you!For any questions or concerns, email Jamie@ChangingMindsPsych.Com Forms You Will Need Direct Deposit Form W9 Form
