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Become an MedBetter Health Provider
Please fill out this form below correctly and we will get back to you.
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1. Personal Information
Full Name
Phone Number
Email Address
2. Do you hold a license in any of the following states? (select all that apply)
New York
New Jersey
Connecticut
Massachusetts
I am currently a student
N/A
Other
Other (select)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
3. Do you have DEA in any of the following states? (select all that apply)
New York
New Jersey
Connecticut
Massachusetts
Other
Other (select)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
4. Are you PMHNP Board-Certified?
Yes
No
5. Do you hold any additional board certifications, such as FNP, AGACNP, PNP, etc.??
Yes
No
6. Are you comfortable with providing Talk therapy with Medication Management?
Yes
No
7. Which of these ages are you comfortable seeing? (select all that apply)
5 - 13 years
14 - 17 years
18 - 64 years
65+ years
8. Do you have any previous experience in providing mental health care?
Yes
No
9. Do you have any experience with prescription management?
Yes
No
10. Please upload a copy of your CV/Resume.(PDF Only)
Submit Form
