Provider Registration

Provider Registration 2016-09-02T16:22:21+00:00

 

If you are a mental health provider in the United States, we invite you to register to be listed on our Mental Health Provider Network. Registration is free. Approved providers will display on the Provider Directory page which is available to anyone who is looking for a South Asian mental health provider.

Eligibility: Mental health providers of any discipline, e.g., psychiatrists, psychologists, social workers, nurse practitioners, etc. of South Asian origin who are licensed to practice.

By completing this registration form, you grant SAMHIN permission to publish your information on our website. Note: The email field is for SAMHIN use only to contact you - it will not display on your provider directory listing.

After you submit the application, every effort will be made to publish your listing within one week. You will receive an email notification after your application is processed.

 

Your Information

Essential Information

Organization / Company / Full Name (for private practice)*
For private practice, you can enter your degree after your name. Example: John Smith, MD
Practice Type*
Select the category that best describes your practice. (If you have a second location, there are additional fields below to enter the details.)
Contact First and Last Name
Contact Company
Contact Job Title and Department
Location*
(Note: If you enter a suite number and your address does not display in the drop down options, omit the suite number, select your address, and then add the suite number.)
Address Line 1
City
State / Province / Region
Postal / Zip Code
Country
Latitude
Longitude

Contact Information

Phone Number
E-mail
Website
Second Location Address
If you have a second location, enter the address details below.
Address Line 1
City
State / Province / Region
Postal / Zip Code
Country
Latitude
Longitude
Second Location Phone
If you have a second location, enter the phone number below.

Social Accounts

Twitter
Facebook URL
Google+ URL

Additional Information

Specialty
Enter your specialties, e.g., child and adolescent psychiatry, addiction, etc.
Degree(s)
Enter your degrees and / or certifications.
Treatment(s) Offered
Enter the treatments you offer, e.g., psychotherapy, medication management, etc.
Country of Origin
Enter the country where you are from.
Languages
Enter languages you speak fluently. Example: English, Hindi
Gender
Insurance Accepted
Do you accept insurance?
Medicare Accepted
Do you accept Medicare?
Medicaid Accepted
Do you accept Medicaid?
Evening Hours
Are you available for evening appointments?
Saturday Hours
Are you available for Saturday appointments?
Listing Description
Enter a short paragraph about your practice or any additional affiliations such as universities.
Photos
Upload an optional head shot.
File Name Size
There are currently no files uploaded.
Maximum file size 2MB.
Supported file formats: gif jpeg jpg png