Personal & Professional InformationName:(Required) First Last Professional Credentials:(Required) MD DO PMHNP Other Please enter your License Number & State(s) of Licensure:(Required)What is your preferred contact method?(Required) Email Phone Number Website Email:(Required) Phone Number:(Required)Website:(Required) Please enter the city & state of your primary practice:(Required)Organization/Employer (if applicable):Please upload your headshot for our website:Max. file size: 50 MB.CFHA Membership Confirmation:(Required) I confirm that I am an active CFHA member Clinical Services OfferedType of Consulting Roles Available (Check all that apply):(Required) CoCM Consulting Psychiatry General Consulting Psychiatry E-Consultations Other If you selected "Other," please list the consultation Roles here:Availability (Check all that apply):(Required) In-person Remote/Telepsychiatry Hybrid (In-person & Remote) If you selected "In-person," please specify the locations:Patient Populations Preferences (Check all that apply):(Required) Pediatric Adolescent Adult Geriatric Other If you selected "other," please specify:Languages Spoken:(Required)Brief Bio (Professional Background & Experience in Integrated Care):(Required)Do you have prior experience working in CoCM?(Required) Yes No Some experience If you selected "some experience," please specify here:Additional Areas of Expertise (e.g., substance use disorders, perinatal psychiatry, serious mental illness, etc.):Why should someone consult with you? Please give a brief sentences in 100 characters or less:(Required)Practice & LogisticsPlease enter any affiliations with health systems, clinics, or other organizations:(Required)Consultation Fee Structure (if applicable):(Required) Fee-for-service Contract-based Hourly Other Are you currently accepting new consultation opportunities?(Required) Yes No Maybe If you selected "maybe," please specify:Preferred Method of Contact for Potential Collaborators:(Required) Email Other Submission AgreementSubmission Agreement(Required)By submitting this form, you agree that the information provided will be shared publicly on CFHA’s technical assistance website to facilitate connections between consulting psychiatrists and clinical sites in need of services. CFHA reserves the right to verify membership and credentials prior to posting. I agree to the terms above and certify that the information provided is accurate. Date MM slash DD slash YYYY Untitled First Choice Second Choice Third Choice CommentsThis field is for validation purposes and should be left unchanged.
