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Application for Listing in the OPUS Hypnotherapist/ Mental Health Provider Network

1. IDENTIFYING INFORMATION

2. OPUS Network - Find us

3. UNDERGRADUATE EDUCATION

4. GRADUATE/PROFESSIONAL EDUCATION

5. HYPNOSIS/HYPNOTHERAPY TRAINING

6. CERTIFIED HYPNOTHERAPIST

Are you a certified hypnotherapist?

7. MEDICAL DOCTOR, MENTAL HEALTH PRACTITIONER OR THERAPIST

Are you a medical doctor?
Are you a mental health practitioner or therapist?

8. CONTINUING PROFESSIONAL EDUCATION

Do you participate in continuing education in support of your certification or license?

9. PRACTICE

Are you in private practice?

10. OTHER APPLICABLE EMPLOYMENT

11. PROFESSIONAL ORGANIZATIONS

Are you affiliated with any professional organizations?

12.​ PROFESSIONAL LIABILITY INSURANCE

Do you carry Professional Liability Insurance?
Have any judgments or settlements been made against you in professional liability cases or are any cases pending?
Have you been convicted of a felony?

13.​ PRIOR EXPERIENCE

14.​ PAYMENT FOR SERVICES

Do you accept insurance for payment of fees

15.​ PROFESSIONAL REFERENCES

16. ADDITIONAL DOCUMENTS

PLEASE ATTACH COPIES OF THE FOLLOWING DOCUMENTS TO THIS APPLICATION. YOUR APPLICATION CANNOT BE CONSIDERED WITHOUT ALL THESE DOCUMENTS. IF YOU ARE UNABLE TO UPLOAD THEM TO THIS FORM, PLEASE EMAIL THEM TO OPUS IN A SEPARATE EMAIL.

  • Your resume or curriculum vitae

  • Copy of State license or certification showing Expiration Date

  • Liability insurance fact sheet

  • A brief description of your practice, services, name and contact information to be included in your OPUS network listing.

15. PLEASE READ, UNDERSTAND AND AGREE TO THIS DISCLAIMER

OPUS maintains a provider network referral list for use in accomplishing its goals and mission. As such, it may refer individuals to therapists or mental health professionals on its provider network referral list, as appropriate. However, OPUS has no legal, financial or business relationship with, or obligation to, any member of its provider network or provider referral list, nor does OPUS agree to recommend, refer or endorse any specific individual or organization on the list. OPUS does not provide medical advice or instruct individuals to seek professional services. Provider network members are responsible for managing their own practice and business, and will receive no direction from or remuneration from, and have no obligation to, OPUS. Certain risks are inherent in accepting referrals from any organization, and the provider agrees to accept all risks and responsibility for any individual it accepts as a client. Under no circumstances will OPUS be liable for any damages to a provider in its network or referral list, or any individual referred to a provider after they become a client of the provider, either direct, indirect, incidental, special, punitive, or consequential that result in any way from use or inability to use the referral list. Individuals and organizations on the provider referral list are not employed by OPUS, neither does OPUS pay for the services of any providers it may refer to. Providers in the OPUS network and referral list may terminate their participation at any time with written notice to OPUS at www.opusnetwork.org, and OPUS may terminate any Provider from the network and referral list with notice to the Provider’s email address of record.


By signing this Application, you affirm that you have read and understand the above Disclaimer and the information you have provided herein is accurate and current.

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