888 491 8546 | INFO@RETHINKYOURTHERAPY.COM

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888 491 8546
INFO@RETHINKYOURTHERAPY.COM

SELF ASSESSMENTS | ACTIVATE | LOGIN

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PROVIDER APPLICATION

PROVIDER APPLICATION

JOIN OUR NETWORK

WE ARE ALWAYS LOOKING FOR QUALIFIED PROVIDERS TO JOIN OUR NETWORK.

PLEASE COMPLETE THE APPLICATION QUESTIONAIRE SO WE CAN CONSIDER ADDING YOU TO OUR NETWORK.

We are excited to hear from you!

PLEASE COMPLETE THE APPLICATION QUESTIONAIRE SO WE CAN CONSIDER ADDING YOU TO OUR NETWORK.

We are excited to hear from you!

1Personal Info

2Insurance and Malpractice

3Licensing

4NPI Information

FULL NAME*
First Last
MOBILE PHONE*
EMAIL ADDRESS*
YOUR CURRENT LOCATION*
City State / Province / Region ZIP / Postal Code

HAVE YOU PRACTICES TELE-HEALTH BEFORE?*
- YES, i HAVE.
- NO, TELE-HEALTH IS NEW FOR ME
DO YOU HAVE 3 YEARS OR MORE OF DIRECT CLINICAL EXPERIENCE?*
- YES
- NO
DO YOU HAVE INDEPENDENT MALPRACTICE INSURANCE COVERAGE?*
- YES, I HAVE MALPRACTIC COVERAGE
- NO, I DO NOT HAVE COVERAGE
PLEASE UPLOAD YOUR MALPRACTICE COVERAGE SHEET
Accepted file types: png, pdf, jpg, doc, docx, Max. file size: 8 MB.
Please upload (as a PDF, JPG, Word doc, or screenshot), a cover sheet of your Malpractice Insurance. It must include the following: your name, a coverage period (beginning and end dates), and the occurrence/aggregate amounts. If the file does not include these, you will be asked to resubmit the file.

WHAT TYPE OF LICENSE DO YOU HAVE?*
- CP - Clinical Psychologist
- CSW - Clinical Social Worker
- PC - Profesional Counselor
- MFT - Marriage and Family Therapist
- OTHER
OTHER LICENSE
PLEASE ENTER THE LICENSE YOU MAINTAIN
IN WHICH STATES ARE YOU LICENSED TO PRECTICE?*
- ALABAMA
- ALASKA
- ARIZONE
- ARKANSAS
- CALIFORNIA
- COLORADO
- CONNECTICUT
- DELAWARE
- DISTRICT OF COLUMBIA
- FLORIDA
- GEORGIA
- HAWAII
- IDAHO
- ILLINOIS
- INDIANA
- IOWA
- KANSAS
- KENTUCKY
- LOUISIANA
- MAINE
- MARYLAND
- MASSACHUSETTS
- MICHIGAN
- MINNESOTA
- MISSISSIPPI
- MISSOURI
- MONTANA
- NEBRASKA
- NEVADA
- NEW HAMPSHIRE
- NEW JERSEY
- NEW MEXICO
- NEW YORK
- NORTH CAROLINA
- NORTH DAKOTA
- OHIO
- OKLAHOMA
- OREGON
- PENNSYLVANIA
- RHODE ISLAND
- SOUTH CAROLINA
- SOUTH DAKOTA
- TENNESSEE
- TEXAS
- UTAH
- VERMONT
- VIRGINIA
- WASHINGTON
- WEST VIRGINIA
- WISCONSIN
- WYOMING
- ARMED FORCES - AMERICAS
- ARMED FORCES - EUROPE
- ARMED FORCES - PACIFIC

DO YOU HAVE A NATIONAL PRIVIDER IDENTIFICATION (NPI) NUMBER?*
- YES, I HAVE A NPI NUMBER
- NO, I DO NOT
WHAT IS YOUR NPI NUMBER?

ASSESSMENTS

POSTTRAUMATIC STRESS
ANXIETY ASSESSMENT
MANIA
SLEEP DISTURBANCE
MOOD DISORDER
DEPRESSION
SUBSTANCE ABUSE
SOMATIC SYMPTOM
REPETITIVE THOUGHTS
DSM – CROSS-CUTTING

RESOURCES

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FOR PROVIDERS
TELE-MEDICINE
PRESS AND MEDIA
TERMS OF SERVICE
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WHAT WE TREAT
JOIN RETHINK

POWERED BY

telehealth services provided by Walmart Health

If you are in crisis, call the National Suicide Prevention Lifeline, a free, 24-hour hotline, at 1.800.273.8255.

If this is an emergency, call 911 or go to your nearest emergency room. Rethink My Healthcare does not offer crisis counseling or emergency services.

Walmart Health Virtual Care offers medical consultations, behavioral health counseling, and talk therapy services via telehealth to patients nationwide. Services are provided in accordance with state law by licensed professionals and are rendered subject to the licensed professionals’ judgment. When medically necessary, Walmart Health Virtual Care providers may prescribe medication to patients; Walmart Health Virtual Care does not guarantee that a prescription will be written. Walmart Health Virtual Care is not a pharmacy or prescription fulfillment warehouse. Walmart Health Virtual Care is not an insurance product. Virtual Urgent Care visits are not a replacement for a primary care physician.

COPY RIGHT 2022 – RETHINK MY HEALTHCARE INC.

WEBSITE DESIGNED BY SELO INTERNATIONAL

POWERED BY

telehealth services provided by Walmart Health

SUPPORT

CONTACT US
GIFT CARDS
PROGRAM PRICES
SESSION PRICES
WHAT WE TREAT
JOIN RETHINK

ASSESSMENTS

POSTTRAUMATIC STRESS
ANXIETY ASSESSMENT
MANIA
SLEEP DISTURBANCE
MOOD DISORDER
DEPRESSION
SUBSTANCE ABUSE
SOMATIC SYMPTOM
REPETITIVE THOUGHTS
DSM – CROSS-CUTTING

RESOURCES

BLOG
FOR PROVIDERS
TELE-MEDICINE
PRESS AND MEDIA
TERMS OF SERVICE
PRIVACY POLICY

If you are in crisis, call the National Suicide Prevention Lifeline, a free, 24-hour hotline, at 1.800.273.8255.

If this is an emergency, call 911 or go to your nearest emergency room. Rethink My Healthcare does not offer crisis counseling or emergency services.

Walmart Health Virtual Care offers medical consultations, behavioral health counseling, and talk therapy services via telehealth to patients nationwide. Services are provided in accordance with state law by licensed professionals and are rendered subject to the licensed professionals’ judgment. When medically necessary, Walmart Health Virtual Care providers may prescribe medication to patients; Walmart Health Virtual Care does not guarantee that a prescription will be written. Walmart Health Virtual Care is not a pharmacy or prescription fulfillment warehouse. Walmart Health Virtual Care is not an insurance product. Virtual Urgent Care visits are not a replacement for a primary care physician.

COPY RIGHT 2022 – RETHINK MY HEALTHCARE INC.

WEBSITE DESIGNED BY SELO INTERNATIONAL

POWERED BY

telehealth services provided by Walmart Health

ASSESSMENTS

POSTTRAUMATIC STRESS
ANXIETY ASSESSMENT
MANIA
SLEEP DISTURBANCE
MOOD DISORDER
DEPRESSION
SUBSTANCE ABUSE
SOMATIC SYMPTOM
REPETITIVE THOUGHTS
DSM – CROSS-CUTTING

RESOURCES

BLOG
FOR PROVIDERS
TELE-MEDICINE
PRESS AND MEDIA
TERMS OF SERVICE
PRIVACY POLICY

SUPPORT

CONTACT US
GIFT CARDS
PROGRAM PRICES
SESSION PRICES
WHAT WE TREAT
JOIN RETHINK

If you are in crisis, call the National Suicide Prevention Lifeline, a free, 24-hour hotline, at 1.800.273.8255.

If this is an emergency, call 911 or go to your nearest emergency room. Rethink My Healthcare does not offer crisis counseling or emergency services.

Walmart Health Virtual Care offers medical consultations, behavioral health counseling, and talk therapy services via telehealth to patients nationwide. Services are provided in accordance with state law by licensed professionals and are rendered subject to the licensed professionals’ judgment. When medically necessary, Walmart Health Virtual Care providers may prescribe medication to patients; Walmart Health Virtual Care does not guarantee that a prescription will be written. Walmart Health Virtual Care is not a pharmacy or prescription fulfillment warehouse. Walmart Health Virtual Care is not an insurance product. Virtual Urgent Care visits are not a replacement for a primary care physician.

COPY RIGHT 2022 – RETHINK MY HEALTHCARE INC.

WEBSITE DESIGNED BY SELO INTERNATIONAL