1. Are you licensed or certified by a state(s)? *
2. If you have been the subject of any investigations, reviews, or disciplinary action taken against you by a licensing board related to your practice, then please provide a brief description of the events.*
3. How many years of experience do you have doing this work?
4. Please list your highest level of education - Include institution, degree, and year of graduation.
5. Do you hold any certification(s) or accreditation(s)?*
6. What title do you use to describe your credentials and practice? (e.g. Licensed Professional Counselor, Peer Recovery Coach, Life Coach)
7. Do you maintain the state-mandated level of professional liability insurance?*
8. Do you accept insurance(s) as payment?*
9. What is your National Provider Identifier (NPI) number?
Description of Services
Please write a short description of your services to be shared on your public profile for potential clients to read when choosing a treatment professional. (250 characters max)*
If you provide in patient treatment services, how many total number of beds do you have?*
Select your Specialties or Areas of Focus*
How will you use Sober Peer?
1. On average, how many hours a week are you available to work with Sober Peer?
2. Please check the languages in which you are able to provide services.*
3. Describe your experience coaching online or via a telehealth solution.*
Have you used zoom, go-to-meeting, web-ex, Microsoft teams, or another telehealth platform, etc?
1. How did you hear about Sober Peer?
3. I agree to not use the Sober Peer platform to perform any services for which I am not licensed, certified, or otherwise qualified to provide.