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IL New Staff

IL - New Staff Hire

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Accepted file types: pdf, Max. file size: 300 MB.
    List your primary office and any other practice locations.
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    Accepted file types: pdf, jpeg, png, Max. file size: 300 MB.
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      Accepted file types: pdf, jpeg, png, Max. file size: 300 MB.
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        Accepted file types: pdf, jpeg, png, Max. file size: 300 MB.
          Must include the following: 1. All start/end dates formatted for all sections (mm/yyyy) 2. LifeStance Health added as current employer 3. Must list at least five years of employment history (or from date of licensure if less)
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          Accepted file types: pdf, Max. file size: 300 MB.
            Upload additional liability insurance you plan to maintain. *This is not required. You’re covered by LifeStance, but we need a copy of other policies for Credentialing purposes.
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            Accepted file types: pdf, Max. file size: 300 MB.
              Ages Served (select all that apply)(Required)
              Areas of Treatment (select all that apply)(Required)
              This list is used by intake to filter available therapists in the matching process. For issues you don’t select, a client that calls with that presenting issue will NOT be placed with you.
              Communities Served (select all that apply)(Required)
              List Name, Title/Role/Degree, Phone, Fax, and Email Address
              List Name, Title/Role/Degree, Phone, Fax, and Email Address
              List Name, Title/Role/Degree, Phone, Fax, and Email Address
              Please see photo guidelines featured in the link above this form.
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              Accepted file types: jpeg, png, Max. file size: 300 MB.