Provider Registration

Provider Info
Additional Contact Info
How Did You Hear?
Demographics
Confidentiality

Step 1: Provider Information

First Name * Last Name * Provider NPI # * Email * Practice/Work Phone * Phone Extension Provider Type * Other Provider Type * Specialty * Other Specialty * Number of Years in Practice * The provider is a Trainee? * Trainee Type * Other Medical Trainee Description * Date When Training Will End * Specialty Mental Health Training? * Describe Previous Mental Health Training *

Step 2: Additional Contact Information

Home Phone Mobile Phone

Step 3: How Did You Hear About Us?

APAL or HealthHaven Staff

APAL or HealthHaven Enrolled Provider

Friend or Colleague

My Medical or Specialty Association

Social Media

Search Engine

News Story

Presentation or Exhibit

Other

How did you hear about APAL? (Other) *

Step 4: Provider Demographics

Do you think of yourself as How do you identify with respect to Race? Provider Race Description * Provider Language (other than English) Other Languages *

Step 5: Confidentiality

Opt-out

Thank you for registering with APAL! As our program grows, we will keep you informed about educational opportunities and access to the APAL line. Questions? Contact [email protected].