PROVIDER NETWORK Introducing S.P.U.R. @ The Incite Center Join The Incite Provider Network - Membership Now Open **** Join The Incite Provider Network - Membership Now Open **** Join The Incite Provider Network - Membership Now Open **** Apply Here INCITE PROVIDER NETWORK Form Demographics Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date Of Birth * MM DD YYYY Social Security Number * Email * Phone (###) ### #### Professional Information Professional Title LPC LPCC Other License Number * Issuing State * Expiration Date MM DD YYYY Professional Experience Primary Counseling Focus Please Select One or More Individual Therapy 18-99 Couples Therapy Child/Adolescent Therapy Addiction / Substance Use Counseling Career Counseling Trauma Informed Counseling Females Only Males Only Reproductive Mental Health Other (please specify) Years of Experience * 0-1 Years 2-5 Years 6-10 Years 10+ Years Membership Enrollement Membership Level * S.P.U.R (postgraduate unlicensed) IGNITE Provider Network (Fully Licensed) Network Affiliate Membership Duration Annual (12 months) BiAnnual (Every 2 years) Member Benefits (Select All That Apply) What member benefits would be most valuable to you? Access to Advanced Supervision & Training Access to Professional Development Contracted Patient Referrals Administration Support Access to a Robust Provider Team and Peer Support Professional Full Service Counseling Space In Network Contracting Other Professional Ethics * As a member of The Incite Center Provider Network, I agree to uphold the ethical standards set forth by the organization and practice in accordance with the applicable licensing and regulatory standards. I agree to adhere to the code of ethics. Additional Information Why do you want to join The Incite Provider Network? Please share why you are interested in becoming a member. Would you be interested in serving in any leadership capacity? if yes, please describe your interest or area of expertise. Do you have any special skills, services, certifications or contributions you would like to offer to the network? Please describe below: Membership Dues and Payments Membership Payment Method * Payment Method S.P.U.R. / IGNITE (Auto Withdrawel from Contract Fee Agreement) Affiliate (Auto Withdrawel from Bank Checking/Savings Account.) Affiliate (Check) Affiliate Membership Dues Annual $500.00 SPUR & IGNITE Application Fee This is a one-time fee collected at the time of membership registration. The fees collected are used toward the costs associated with membership creation, identification badges, and the creation of office keys for each member. $12.50 Consent & Signature * By submitting this application, I agree to abide by the rules, regulations and code of ethics of The Incite Provider Networks: SPUR/IGNITE. I confirm that the information provided above is accurate to the best of my knowledge. Thank you!
