Behavioral Health Provider Questionnaire Question Title * 1. Name, Degree Question Title * 2. HNE 5-Digit Provider ID# Question Title * 3. Email address Question Title * 4. Website address Question Title * 5. Complete office hours detail Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: Question Title * 6. Extended office hours Evening hours Weekend hours Question Title * 7. Office handicapped accessible? Yes No Question Title * 8. Do you E-Prescribe, if applicable? Yes No Question Title * 9. Do you have Electronic Medical Records (EMRs)? Yes No Question Title * 10. Do you treat the Hearing Impaired / offer Sign Language? Yes No Question Title * 11. Languages spoken by provider in addition to English Question Title * 12. Are you accepting new patients? Yes No Question Title * 13. What ages do you treat? Question Title * 14. Services provided - Check all that apply ADOLESCENTS ADULTS CHILDREN GERIATRICS ACCEPTANCE AND COMMITMENT THERAPY (ACT) APPLIED BEHAVIORAL ANALYSIS AUTISM SPECTRUM DISORDERS (ASD) DIAGNOSIS & TREATMENT BISEXUAL/GAY/LESBIAN/TRANSGENDER COGNITIVE BEHAVIORAL THERAPY (CBT) DIALECTICAL BEHAVIOR THERAPY (DBT) EATING DISORDER TREATMENT EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR) GROUP THERAPY MARRIAGE AND FAMILY THERAPY NARRATIVE THERAPY NEURO-PSYCHOLOGICAL TESTING OBSESSIVE-COMPULSIVE DISORDER POST-TRAUMATIC STRESS DISORDER PSYCHODYNAMIC PSYCHOTHERAPY PSYCHOLOGICAL TESTING REACTIVE ATTACHMENT DISORDER (RAD) REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (RTMS) SUBSTANCE ABUSE TRAUMA FOCUSED COGNITIVE BEHAVIORAL THERAPY (TFCBT) TRAUMA INFORMED TREATMENT Please visit the Provider Search on HNE.com to view your current listing and notify us of any additional changes. (http://www.healthnewengland.com/Provider_Lookup_Direct/Default.aspx) Done