Provider Member Application — Elevate Health Collective Chippewa Valley

Provider Member Application Form

Welcome! Thank you for your interest in joining the Elevate Collective. We are excited to get to know you and determine if we're the perfect match for each other.

Kindly complete our application form, and a dedicated member of the team will be in touch with you within 1-2 business days. We appreciate your interest!

We will be a perfect match if you…

You value the sense of belonging within a community and appreciate the invaluable benefits it brings.
Continuous personal and professional development is a cornerstone of your ethos.
You embrace collaboration with fellow mental health and wellness providers, valuing cooperation over competition in serving clients.

Name

First Name

Last Name

Phone

(will not be listed)

(###)

###

####

License Number

If applicable

Degree(s) or Professional Training

Have you ever been the subject of any disciplinary action or malpractice claim?*

*I affirm that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in the application may render this application void and will be cause for termination, legal action, and reporting to the appropriate parties. Elevate Health Collective is committed to protecting and respecting your privacy. We’ll only use your information to administer your account and provide the services you requested. You can unsubscribe from these communications at any time in accordance with our Privacy Policy. By clicking submit, you consent to Elevate Health Collective to store and process the personal information submitted above to provide you the content requested.

I agree to receive communications from Elevate Health Collective.