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FULL NAME*
First Last
MOBILE PHONE*
EMAIL ADDRESS*
YOUR CURRENT LOCATION*
City State / Province / Region ZIP / Postal Code

HAVE YOU PRACTICES TELE-HEALTH BEFORE?*
- YES, i HAVE.
- NO, TELE-HEALTH IS NEW FOR ME
DO YOU HAVE 3 YEARS OR MORE OF DIRECT CLINICAL EXPERIENCE?*
- YES
- NO
DO YOU HAVE INDEPENDENT MALPRACTICE INSURANCE COVERAGE?*
- YES, I HAVE MALPRACTIC COVERAGE
- NO, I DO NOT HAVE COVERAGE
PLEASE UPLOAD YOUR MALPRACTICE COVERAGE SHEET
Accepted file types: png, pdf, jpg, doc, docx, Max. file size: 2 MB.
Please upload (as a PDF, JPG, Word doc, or screenshot), a cover sheet of your Malpractice Insurance. It must include the following: your name, a coverage period (beginning and end dates), and the occurrence/aggregate amounts. If the file does not include these, you will be asked to resubmit the file.

WHAT TYPE OF LICENSE DO YOU HAVE?*
- CP - Clinical Psychologist
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- MFT - Marriage and Family Therapist
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OTHER LICENSE
PLEASE ENTER THE LICENSE YOU MAINTAIN
IN WHICH STATES ARE YOU LICENSED TO PRECTICE?*
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DO YOU HAVE A NATIONAL PRIVIDER IDENTIFICATION (NPI) NUMBER?*
- YES, I HAVE A NPI NUMBER
- NO, I DO NOT
WHAT IS YOUR NPI NUMBER?

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telehealth services provided by Walmart Health

If you are in crisis, call the National Suicide Prevention Lifeline, a free, 24-hour hotline, at 1.800.273.8255.

If this is an emergency, call 911 or go to your nearest emergency room. CJS Healthcare Advisors does not offer crisis counseling or emergency services.

Walmart Health Virtual Care offers medical consultations, behavioral health counseling, and talk therapy services via telehealth to patients nationwide. Services are provided in accordance with state law by licensed professionals and are rendered subject to the licensed professionals’ judgment. When medically necessary, Walmart Health Virtual Care providers may prescribe medication to patients; Walmart Health Virtual Care does not guarantee that a prescription will be written. Walmart Health Virtual Care is not a pharmacy or prescription fulfillment warehouse. Walmart Health Virtual Care is not an insurance product. Virtual Urgent Care visits are not a replacement for a primary care physician.

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