Allied Trades Assistance Program

How would you like your facility/provider name and address to appear in our system?

Servicing Address


What is your billing address (if different from above)?


What is the best phone number for ATAP to give to members when they are
seeking a referral?

What is the best fax number for your office?

What is the best email address for your office?

Tax ID#

Which of the following types of services does your provider/facility offer?
Please check all that apply. (Please select one or more options below)
Inpatient mental health servicesPartial hospitalization mental health servicesIntensive outpatient mental health servicesOutpatient mental health servicesInpatient substance use disorder servicesPartial hospitalization substance use disorder servicesIntensive outpatient substance use disorder servicesOutpatient substance use disorder services
Which of the following applies to your practice?
Please check all that apply. (Please select one option below)
No Telehealth ServicesOffering Telehealth ServicesSolely a Telehealth Practice
Which of the following specialties does your provider/facility offer? Please check all that apply. (Please select one or more options below)
ACOAADD/ADHDADD/ADHD testingAdjustment disordersAdoption issuesAnger managementAnger Management GroupsAnxiety disordersArt TherapyAutismAutism testingBariatric/Gastric bypass surgery evaluationsBiofeedbackCareer issuesChild abuse issuesChild/adolescent disordersChildren's GroupsCritical incident stress debriefingCognitive behavioral therapyCompulsive gamblingDBT Dialectical Behavioral TherapyDepressionDetoxificationDevelopmental disordersDisease managementDissociative disordersDomestic violenceDual diagnosisEating disordersEMDRExposure and Response Prevention (ERP)FamilyFertility/InfertilityFinancialForensicLGTBQIA+Gender AffirmationGender and Sexual IdentityGrief and Loss/BereavementGroupHandicap Accessible LocationHIV/AIDS/ARCHypno-TherapyHolistic HealingIndividual TherapyLearning disabilitiesMarital/couples/divorce/separationMedication management/PsychiatryMen's issuesMood disordersMulti-cultural issuesMusic TherapyNeuro-psych evaluationsObsessive compulsive disorderPain managementParentingPersonality disordersPhobiasPhysical abusePlay therapyPost-traumatic stress disorder (PTSD)Post-partum depressionPsychological testingReligious/spiritualSchizophreniaSelf-injurious BehaviorSexual abuseSexual addictionSexual disordersSexual dysfunctionSexual orientationSexual traumaSex Offender TreatmentSleep disordersSports PerformanceStress managementTraumaTreatment of Sexual offendersTMSVeteransWellnessWomen's issuesWork/Employment issuesOther (please specify):

What types of clients does your provider/facility serve? Please check all that
apply. (Please select one or more options below)
Children under age 5Children aged 5-10Children aged 10-14Adolescents aged 14-18Adults aged 18+Older adults 50+Males onlyFemales only
Does your provider/facility have a child therapist on staff?
YesNo
Is your provider/facility currently accepting new clients?
YesNo
Does your provider/facility have a child psychiatrist on staff?
YesNo
Languages spoken other than English?

Is your provider/facility in network with the following Insurances? (Please select one or more options below)
AetnaCigna/EvernorthHorizonBlue Cross PPOIndependence BCBSMagellanMultiPlanUnited HealthCareOut of networkNone of the above
If there is any other information that you think is important for ATAP to have,
please describe below.

Upload a copy of your liability insurance in PDF or MS Word format.

Upload a copy of your State License in PDF or MS Word format.

Upload a copy of your W9 in PDF or MS Word format.