You can always press Enter⏎ to continue
For Clinics: Find a Psychiatrist
1
What is your job title?
*
This field is required.
CEO/Executive Director
CMO/Clinical Director
Administrator
Program Manager
Behavioral Health Clinician
Patient
Previous
Next
Submit
Press
Enter
2
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
3
Phone Number
*
This field is required.
Area Code
Phone Number
Previous
Next
Submit
Press
Enter
4
Email
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
5
Organization Name
*
This field is required.
Previous
Next
Submit
Press
Enter
6
Facility Type
*
This field is required.
Community Mental Health Center
Federally Qualified Health Center
Correctional Facility
Assisted Living Facility
Primary Care Practice
Hospital
Substance Use Facility
Inpatient Facility
Residential
Previous
Next
Submit
Press
Enter
7
What state are you located in?
*
This field is required.
Previous
Next
Submit
Press
Enter
8
Coverage Need
*
This field is required.
Psychiatrist
Nurse Practitioner
Video/EMR Platform
Previous
Next
Submit
Press
Enter
9
Medical Specialty
Addiction
Child & Adolescent
Forensic
Geriatric
Pain Medicine
Previous
Next
Submit
Press
Enter
10
Position details
Part-Time
Full-Time
Previous
Next
Submit
Press
Enter
11
Are you interested in learning more about our new ProviderShare program
Yes
No
Previous
Next
Submit
Press
Enter
12
How did you hear about us?
*
This field is required.
Google Search
Referred by friend/colleague
Referred by Genoa Healthcare pharmacist
Email
Conference
LinkedIn
Facebook
Behavioral Health Association
Google Search
Referred by friend/colleague
Referred by Genoa Healthcare pharmacist
Email
Conference
LinkedIn
Facebook
Behavioral Health Association
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
12
See All
Go Back
Submit