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Full Intentions Onboarding - Credentialing Info

Welcome to Full Intentions!

We’re so glad you’re here. This onboarding form helps us gather your professional information so we can set you up for success. Please complete all sections carefully — it should take about 10 minutes. If you have any questions, email info@fullintentions.life

General Information

First Name

Last Name

What are your pronouns?

Email Address

Phone Number

Home Address

Date of Birth

Emergency Contact

Full Name

Phone Number

Professional Credentials

License Type and Number

State of Licensure

Additional States of Licensure

NPI Number

CAQH Number

CAQH Username

CAQH Password

If you don't have a NPI or CAQH number just yet we will work on getting you one!

Username and password will be used to complete insurance credentialing on your behalf. If you aren't comfortable with providing this information just let us know and we can walk you through how to do it!

Supervision Information (only for associate level clinicians)

Supervisor First Name

Supervisor Last Name

Supervisors License Number

Supervisors License Type

Supervisors State of Licensure

Confirmation of Supervision

Acceptable forms of confirmation include:

Email from supervisor, a signed letter on letterhead from supervisor or a forwarded email where supervisor explicitly approves and confirms supervision status. Emails can be forwarded or sent directly to info@fullintentions.life

Confirmation must state supervision start date, that supervision is currently active and covers clinical hours earned at Full Intentions, PLLC

Do you have malpractice insurance?

If yes, please upload a copy

Please upload a copy of your license

Please upload a copy of your completed W9

Final Acknowledgement

By submitting this form, I confirm that all information is true and accurate to the best of my knowledge.

Untitled checkboxes field

I agree

Signature

Welcome to the Team!