*Preceptor Name
*Address
*Practice Name
Address2
*City
*Phone
*Email Address
State PA AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code
Fax
*Average number of patients seen per day/provider
*Do you routinely evaluate and manage patients for any of the following conditions: depression, anxiety, ADHD, nocitine dependence, substance abuse and other behavioral concerns? Yes No
*Preceptor Credentials MD DO PA NP CNM Other
If Other, please specify
*State License Number
*Are you board certified?Yes No
If certified, year of certification
*Specialty
*Preferred method of contact Email Office Phone Office Fax
(Optional) Please identify the individual designated as our point of contact (if other than preceptor)
Name
Phone
Title
Email Address
