Mental Health Provider Application Please complete the form below. Name *First and last nameEmail Address *Phone number *Please provide licenses you holdPlease provide which states you are licensed in *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingSubmit your cover letter or resumeChoose FileNo file chosenDelete uploaded fileWe accept the following formats: .pdf, .docx, .doc, .png, .jpg. File should be no larger than 10mb.Submit Application