SAMHIN Providers: submit this form to notify us of any changes in your provider directory listing information. We will make every effort to update your listing within one week.

If you would like to apply to be listed in our Provider Directory, please complete the Provider Registration form.

Notes: The email field is for SAMHIN use only to contact you – it will not display on your provider directory listing. Required fields are noted with a *

    Your Name*

    Your Email*

    Organization / Company / Full Name (for private practice) - this is the main title of your current listing*

    Provider Listing Changes

    For the fields below, only enter any NEW or CHANGED information you would like us to update. You can view your current listing on the Provider Directory page.

    MAIN LOCATION

    Street Address

    City

    State

    Zipcode

    Office Phone

    Office Email


    SECOND LOCATION

    Street Address

    City

    State

    Zipcode

    Office Phone


    Website URL

    Twitter URL

    Facebook URL

    Google+ URL

    Specialties (e.g., child and adolescent psychiatry, addiction, etc.)

    Degree (your degrees and / or certifications)

    Treatment(s) Offered (e.g., psychotherapy, medication management, etc.)

    Country of Origin

    Languages

    Insurance Accepted*
    YesNo

    Medicare Accepted*
    YesNo

    Medicaid Accepted*
    YesNo

    Sliding Fee Scale*
    YesNo

    Evening Hours*
    YesNo

    Saturday Hours*
    YesNo

    Practice Description (short paragraph about your practice or any additional affiliations such as universities)

    Photo (jpg or png, maximum 1MB)

    Listing Contact: for practice types Educational Institution, Mental Health Center / Clinic, or Research.

    Contact First and Last Name

    Contact Company

    Contact Job Title and Department