VERIFICATION REQUEST

Please answer all of the questions as completely as possible.


Practice Description. What type of professional practice do you have and what types of therapy do you provide?

What is your Education? Please indicate your highest level and where you were trained.

Washington State License Number, Type of License, credentials and certifications. If you are working toward your license please provide information about what license you are working toward and when is your expected completion date.

References. Do you have any references that can be used to help us verify your practice? Or do you belong to any professional groups that can help us to complete your verification?
If you were referred by one of our Providers, please include their name here.