Purpose: In order to meet the needs of Alameda County’s diverse population, BHCS is seeking licensed mental health providers/practitioners to provide office-based services who meet the preferred criteria under A. and at least one criterion under B. Please see the Provider Responsibilities section of the FAQ page </a>for more information: Instructions: Read the Preferred, Required and Additional sections to see if you are eligible to provide services. Please note BHCS is seeking providers/practitioners that have offices located in the listed areas Fill out the following and indicate which of the following criteria you meet Attach a current resume Submit this Brief Application and resume to: Subject Provider Network Brief Application ‘MHP Name Tax ID# Licensure Type of Individual ERMHS Murphy Caregiver Type/Discipline Service Provider to Assessor Conservatorship Competency take referrals Assessor Evaluator from (Criminal (Children ACCESS Justice)* and Family Services) Race/Ethnicity Asian Filipino Middle Eastern South Asian Please select the categories that most closely matches how Black Latino Native American Other you identify Caucasian Pacific Islander Please select the categories that most closely matches how you identify. This is an optional section. Lesbian Queer Gay Intersex Bisexual Two-Spirited Transgender Straight Gender Female Male Other Primary Office City/Zip Address Phone Fax Email Secondary City/Zip Office Address Fax Email Mailing Address (if City/Zip different from Office Address) Preferred Experience Have been licensed for at least two years Have a breadth of clinical experience, including working with consumers with Medi-Cal Have experience providing eating Certified in eating disorder treatment (Eating Disorder certified providers receive a higher rate) disorder (ED) treatment Not certified, but have a breadth of experience (In order to receive the higher rate, provider applicant will be prompted to complete the Supplemental Questionnaire on Eating Disorders
Purpose: In order to meet the needs of Alameda County’s diverse population, BHCS is seeking licensed mental health providers/practitioners to provide office-based services who meet the preferred criteria under A. and at least one criterion under B. Please see the Provider Responsibilities section of the FAQ page </a>for more information: Instructions: Read the Preferred, Required and Additional sections to see if you are eligible to provide services. Please note BHCS is seeking providers/practitioners that have offices located in the listed areas Fill out the following and indicate which of the following criteria you meet Attach a current resume Submit this Brief Application and resume to: Subject ‘MHP Provider Network Brief Application Name Tax ID# Licensure Type/Discipline Type of Service Individual Provider to take referrals from ACCESS ERMHS Assessor Murphy Conservatorship Assessor (Criminal Justice)* Caregiver Competency Evaluator (Children and Family Services) Race/Ethnicity Please select the categories that most closely matches how you identify Asian Black Caucasian Filipino Latino Middle Eastern Native American Pacific Islander South Asian Other Please select the categories that most closely matches how you identify. This is an optional section. Lesbian Queer Gay Intersex Bisexual Two-Spirited Transgender Straight Gender Female Male Other Primary Office Address City/Zip Phone Fax Email Secondary Office Address City/Zip Fax Email Mailing Address (if different from Office Address) City/Zip Preferred Experience Have been licensed for at least two years Have a breadth of clinical experience, including working with consumers with Medi-Cal Have experience providing eating disorder (ED) treatment Certified in eating disorder treatment (Eating Disorder certified providers receive a higher rate) Not certified, but have a breadth of experience (In order to receive the higher rate, provider applicant will be prompted to complete the Supplemental Questionnaire on Eating Disorders
MHP_Brief_Application.docx