Provider Agreement
By providing my information below, I agree to participate in the Give an Hour network of mental health professionals who are responding to the current mental health needs of U.S. troops and their families. I agree to adhere to the guidelines and expectations outlined here.
Note: Our approval process is not yet fully automated. Expect a delay before final account activation.
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User
First Name
Last Name
User Name
Email
Password
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Company
Website
Office Address
Address
City
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Postal Code
Phone
Fax
Alternate Office Address
Address
City
State	Please Select Alabama Alaska Arizona 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific American Samoa Guam Northern Mariana Islands
Postal Code
Provider
Provider Practice Areas	Individual ServicesGrief and Loss Marital ServicesMedication Evaluation/Management Family ServicesParent Guidance Child ServicesPost-Partum Depression Adolescent ServicesPost-Traumatic Stress Group CounselingSeparation/Divorce Pastoral CounselingSexual Abuse Alcohol/Chemical DependencyTraumatic Brain Injury Anger ManagementGambling Addiction AnxietySexual Addiction Gay, Lesbian, Bisexual and Transgendered (GLBT)
Phone Counseling	I am open to providing services by phone. I am not open to providing services by phone.
Provider Availability	I am accepting new Give an Hour clients I am not accepting new Give an Hour clients
Languages	English/No Bilingual Services NeededKorean American SignRussian ArabicSpanish ChineseTagalog/Filipino FrenchVietnamese GermanOther Japanese
Degree
Discipline
License #1
Licensed In	Please Select Alabama Alaska Arizona 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific American Samoa Guam Northern Mariana Islands
License Expiration	Su M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Today Is 9/2/2010 Clear Date
License #2
Licensed In	Please Select Alabama Alaska Arizona 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific American Samoa Guam Northern Mariana Islands
Second License Expiration	Su M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Today Is 9/2/2010 Clear Date
NPI
UPIN
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