Provider Interest Form
We are so grateful for your interest in helping Backline. Please fill out the following form as best you can.
Contact Information
First Name
Last Name
Email Address
Phone Number
Website
Preferred Pronouns
Ethnicity:
I identify my ethnicity as:
Asian
Black/African
Caucasian/White
Hispanic/Latinx
Native American
Pacific Islander
Other
Prefer not to answer
Other Ethnicity
Gender Identity
Please select...
Female
Male
Transgender Woman
Transgender Man
Nonbinary
Not Listed
Prefer Not To Say
Birthdate
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Country
(if international)
I am a:
Clinician
Wellness Provider
Both (Clinician & Wellness Provider)
Treatment formats
Individual Therapy
Group Therapy
Family Therapy
Marriage/Couples Therapy
Band Mediation
Coaching
Acupuncture
Art Therapy
Audiologist
Breathwork
Chiropractor
Cupping
Dietician
Fitness Instructor
Flotation Therapy
Herablist
Massage Therapy
Meditation
Mindfulness
Neurofeedback
Nutritionist
Personal Trainer
Physical Therapy
Reiki
Sound Therapy
Spiritual Support
Vocal Coaching
Yoga
Clinician Practice Details
Clinical Credentials
PsyD
PhD
LSW
LPCC
LPC-S
LPC
LMSW
LMFT
LMHC
LISW
LGPC
LCSW-C
LCSW
LCPC-S
LCPC
LCADC
LADC
Other
Other Credentials
In-Person:
Do you offer in-person sessions?
Yes (No Telehealth)
No (Telehealth Only)
Hybrid
Languages:
Do you offer sessions in any other language aside from English?
N/A
Spanish
French
German
Chinese
Mandarin
Arabic
Italian
Greek
Hebrew
Hindi
Japanese
Korean
Portuguese
Russian
Swahili
Polish
Vietnamese
Other
Other Language:
If you selected "other", please provide the language(s) below.
Flexible Hours:
Do you have weekend or evening availability?
Yes
No
Free Consultation:
Do you offer free consultation calls?
Yes
No
Licensed:
Are you a licensed clinician?
Yes
No
Provisionally Licensed
Certs/Credentials:
If not licensed, do you hold any certifications or credentials?
I hereby affirm that my professional license has never been suspended or revoked, and I have never been subject to disciplinary action in my professional capacity.
Yes
No
Licensure
(please add for each state you are licensed in)
State
State License Number
If this license has ever been sanctioned or subject to disciplinary action, please provide details below including reason for sanction, state sanction occurred, date of sanction, and date renewed.
Supervisor's Licensure information
Insurance:
Do you accept insurance?
Yes
No
Superbill:
If you do not accept insurance, are you able to provide Superbills?
Yes
No
Plans:
Please specify your accepted plans:
None
Aetna
CareFirst
Cigna
United Healthcare
Aetna CVS Health
Aetna Medicaid
Alabama Coordinated Health Network
Alabama Premier Network
Alignment Health
AllCare Health (Oregon Medicaid)
Alliant Health
AlohaCare (Hawaii Medicaid)
Ambetter
Ambetter Medicaid
Amerigroup
Amerigroup Medicaid
AmeriHealth
AmeriHealth Medicaid
Antidote Health Plan
Anthem Blue Cross Blue Shield
Anthem Blue Cross of California
Arizona Complete Health (Arizona Medicaid)
Aspirus Health
AultCare Insurance
Avera Health
AvMed, Inc. (Florida Medicaid)
Banner University Family Care (Arizona Medicaid)
Blue Care Network of Michigan
Blue Cross Blue Shield
Blue Cross Blue Shield Medicaid
Blue Shield of California
Blue Shield Promise (California MediCal)
Blue Plus (Blue Cross Blue Shield Minnesota)
BlueCare Tennessee (Tennessee Medicaid)
Boston Medical Center HealthNet Plan
BridgeSpan Health Company
Bright Healthcare
Buckeye Health Plan (Ohio Medicaid)
Capital District Physicians’ Health Plan (CDPHP) (New York Medicaid)
Capital Health Plan (Florida Medicaid)
CareFirst Medicaid (Maryland Medicaid)
CareOregon (Oregon Medicaid)
CareSource
CareSource Medicaid
Care1st Health Arizona (Arizona Medicaid)
Celtic Insurance
Celtic Insurance Medicaid (Florida Medicaid)
Centene
Clear Spring Health
Clover Health
Chinese Community Health Plan
Christus Health Plan Louisiana
Cigna Medicaid
Cigna HealthSpring
Colorado Access (Colorado Medicaid)
Colorado Community Health Alliance (Colorado Medicaid)
Common Ground Healthcare Cooperative
Commonwealth Care Alliance
Community Care Alliance of Illinois (Illinois Medicaid)
Community First Health Plan (Texas Medicaid)
Community Health Choice (Texas Medicaid)
Community Health
Community Health Plan of Washington (Washington Medicaid)
CommunityCare
ConnectiCare
Coordinated Care Corporation
Coordinated Care of Washington (Washington Medicaid)
Coz HealthPlans
Dean Health Plan
DenaliCare / Denali KidCare (Alaska Medicaid)
Denver Health Medical Plan
Denver Health Medicaid (Colorado Medicaid)
Devoted Health
Driscoll Health Plan (Texas Medicaid)
EmblemHealth (New York Medicaid)
Fallon Health
Fallon Community Health Plan (Massachusetts Medicaid)
Family Health Network (Illinois Medicaid)
Fidelis Care
Fidelis Care Medicaid
Florida Blue (Blue Cross Blue Shield Florida)
Florida Blue Medicaid
Florida Health Care Plan
Geisinger Health Plan / Geisinger Quality Options
Granite Care (New Hampshire Medicaid)
Green Mountain Care (Vermont Medicaid)
Harmony Health Plans (Illinois Medicaid)
Harvard Pilgrim Healthcare
Hawaii Medical Service Association (Blue Cross Blue Shield Hawaii)
Health Advantage
Health Alliance Medical Plans
Health Alliance Medical Plans Medicaid (Illinois Medicaid)
Health Choice Arizona (Arizona Medicaid)
Health Choice Utah (Utah Medicaid)
Health First
Health First Colorado (Colorado Medicaid)
Health Net of California / Centene (California MediCal)
Health New England (Massachusetts Medicaid)
Health Partners Plan (Pennsylvania Medicaid)
Health Plan of Nevada (Nevada Medicaid)
Health Share of Oregon (Oregon Medicaid)
Healthfirst (New York Medicaid)
HealthPartners, Inc.
HealthPartners Medicaid (Minnesota Medicaid)
HealthyU (Utah Medicaid)
Healthy Blue Medicaid
Hennepin Health (Minnesota Medicaid)
Highmark Health
Highmark Health Medicaid
HMO Partners, Inc.
HMO Medicaid (Nevada Medicaid)
HMSA (Hawaii Medicaid)
Home State Health (Missouri Medicaid)
Hometown Health Plan
Horizon (Blue Cross Blue Shield of New Jersey)
Horizon Medicaid (New Jersey Medicaid)
Humana
Humana Medicaid
HUSKY Health (Connecticut Medicaid)
IlliniCare Health Plan (Illinois Medicaid)
Imperial Insurance
Inclusa (Wisconsin Medicaid)
Independence Blue Cross
Independent Health Association (New York Medicaid)
Inland Empire Health Plan (California MediCal)
Iowa Total Care (Iowa Medicaid)
Itasca Medical Care (Minnesota Medicaid)
Jai Medical Systems (Maryland Medicaid)
Kaiser Permanente
Kaiser Permanente Medicaid
Keystone First (Pennsylvania Medicaid)
LA Care Health Plan (California MediCal)
Lakeland Care, Inc. (Wisconsin Medicaid)
LifeWise
Louisiana Healthcare Connections (Louisiana Medicaid)
Magnolia Health
Magnolia Health Medicaid (Mississippi Medicaid)
MaineCare (Maine Medicaid)
Maryland Physicians Care (Maryland Medicaid)
McLaren Health Plan (Michigan Medicaid)
MDwise (Indiana Medicaid)
Med Star (Maryland Medicaid)
Medica Insurance
Medica Medicaid (Minnesota Medicaid)
MedMutual
Mercy Care
Mercy Care Medicaid
Meridian Health
Meridian Health Medicaid
MetroPlus Health (New York Medicaid)
MinnesotaCare (Minnesota Medicaid)
Moda Health
Molina Healthcare
Molina Healthcare Medicaid/MediCal
Mountain Health Co-Op
Montana State Healthcare (Montana Medicaid)
MVP Health
My Choice Wisconsin (Wisconsin Medicaid)
Nebraska Total Care (Nebraska Medicaid)
Neighborhood Health
Neighborhood Health Medicaid
Network Health
Network Health Medicaid
NH Healthy Families (New Hampshire Medicaid)
North Dakota State Insurance (North Dakota Medicaid)
Northeast Health Partners (Colorado Medicaid)
Octave
Ohana Health Plan (Hawaii Medicaid)
Oklahoma Complete Health (Oklahoma Medicaid)
Optima
Oregon Community Health Options
Oscar Health
Oscar Health Medicaid
PA Health & Wellness (Pennsylvania Medicaid)
PacificSource Health Plans
PacificSource Medicaid (Oregon Medicaid)
Paramount Insurance
Partners Health Management (North Carolina Medicaid)
Partnership HealthPlan of California (California MediCal)
Peach State Health Plan (Georgia Medicaid)
Physicians Health Plan (Michigan Medicaid)
Premera Blue Cross Blue Shield
Presbyterian Health
Presbyterian Health Medicaid (New Mexico Medicaid)
PrimeWest Health (Minnesota Medicaid)
Priority Health
Priority Health Choice Plan (Michigan Medicaid)
Priority Partners (Maryland Medicaid)
QCA Health Plan (Arkansas Medicaid)
QualChoice Life and Health Insurance (Arkansas Medicaid)
Quartz Health Plans
Regence Blue Shield
Rocky Mountain Health Plans
Rocky Mountain Health Plan Medicaid (Colorado Medicaid)
Sanford Health
SCAN Health Plan
Security Health Plan of Wisconsin
SelectHealth
SelectHealth Medicaid (South Carolina Medicaid)
Sentara Health Plans (Virginia Medicaid)
Sharp Health Plan
Sierra Health and Life
SilverSummit Healthplan (Nevada Medicaid)
Simply Healthcare Plans
Simpra Advantage
St. Luke’s Health Plan
South Country Health Alliance (Minnesota Medicaid)
SummaCare
Sunflower State Health Plan (Kansas Medicaid)
Sunshine State Health Plan
Superior HealthPlan (Texas Medicaid)
Taro Health
The Health Plan of West Virginia (West Virginia Medicaid)
Total Healthcare USA (Michigan Medicaid)
Trillium Health Resources (North Carolina Medicaid)
TrueCare (Mississippi Medicaid)
Valley Health Plan (California MediCal)
Vaya Health (North Carolina Medicaid)
Vista Health Plan (Pennsylvania Medicaid)
VIVA Health
VIVA Medicare
UCare Minnesota (Minnesota Medicaid)
UPMC
UPMC Medicaid (Pennsylvania Medicaid)
United Healthcare Medicaid
Univera
University of Utah Health Plans
WellCare
WellCare Medicaid
WellFirst Health
Wellmark Health Plan
WellPoint Health
WellPoint Medicaid
WellSense Health Medicaid Plan
Western Health Advantage
Wyoming State Healthcare (Wyoming Medicaid)
Other
Please note that you can only select a maximum of 100 values here.
Other Insurance:
If other insurance, please list.
Hourly Rate:
What is your hourly rate?
$
Backline Rate:
Are you willing to provide negotiated rates for Backline Clients?
Yes
No
Lowest Fee:
What is your lowest possible fee?
$
Accepted payment methods:
Please select all.
CC
PayPal
Venmo
Cash
Specific populations:
Which specific populations do you feel particularly equipped to serve?
LGBTQIA+
BIPOC
Veterans
Active Duty Military
Neurodivergence
Survivors of Trauma and Abuse
Immigrants and Refuges
Older Adults and Geriatric Clients
Chronic Illness or Disability
Low-income or Housing-insecure clients
Other
Other populations:
If other, please specify.
Work with Underrepresented Groups:
Do you have any special training or experience working with marginalized or
underrepresented communities?
Clinical Experience
Practicing Since
(please input a year)
Theoretical Approach:
Please select all that apply.
Accelerated Experiential Dynamic Psychotherapy (AEDP)
Accelerated Resolution Therapy
Acceptance and Commitment Therapy (ACT)
Accountability Coaching
Addiction Counseling
Adlerian Therapy
Alexander Technique (Pain Disorder Therapy)
Art Therapy
Attachment-Based Therapy
Bio-Filed Tuning
Body-Centered Therapy
Brain Spotting
Breathwork
Brief Therapy
Buddhist Psychology
CBT Plus
Christian Counseling
Cognitive Behavioral Therapy (CBT)
Cognitive Processing Therapy (CPT)
Compassion-Focused
Collaborative Counseling
Creative Arts Therapy
Cultural Relational Therapy (CRT)
Culturally Sensitive Therapy
Dance/Movement Therapy
Developmental Therapy
Dialectical Behavior Therapy (DBT)
EMDR
Emotionally Focused Therapy (EFT)
Equine Therapy
Existential Therapy
Experiential Therapy
Exposure and Response Therapy (ERT)
Expressive Arts Therapy
Family Systems
Feminist Therapy
Gestalt Therapy
Goal-oriented Therapy
Gottman Approach
Hakomi
Harm Reduction
Holistic Approach
Hypnotherapy/Hypnosis
Integrative / Eclectic Approach
Internal Family Systems (IFS)
Interpersonal Psychotherapy (IPT)
Jungian Therapy
Ketamine Assisted Therapy
LGBTQ+ Affirming
Life Coaching
Meditation
Mindfulness
Motivational Interviewing
Multicultural Counseling
Music Therapy
NARM Therapy
Narrative Therapy
Nature-based therapy
Neuro-linguistic Therapy
Person-Centered / Humanistic / Client-Centered
Play Therapy
Positive Psychology/Psychotherapy
Polyvagal Theory
Prolonged Exposure Therapy
Psychedelic-Assisted Therapy
Psychoanalysis
Psychoanalytic Psychotherapy
Psychodrama
Psychodynamic Therapy
Reality Therapy
Rational Emotive Behavioral Therapy (REBT)
Relational Work
Restoration Therapy
RO-DBT
Sand Tray Therapy
Sex Therapy
Social Justice
Solution Focused Therapy
Somatic Therapy
Strengths-Based Therapy
Transpersonal Therapy
Trauma-Focused / Trauma-Informed
Wilderness Therapy
Other
Clinical Specialties:
Please select all areas that apply. You may choose as many options as are appropriate.
Specialty Area
Issue Area Id
Video
If desired, please record and upload a 30-second video introducing yourself to prospective Backline Care clients.
Option 1:
Upload a Video File.
Option 2:
Drop the URL to the video or Google Drive folder below. If you include a URL, please make sure the video is public to anyone with the link.
Wellness Provider Details
This form is intended for wellness practitioners and organizations interested in being a part of our referral network, contributing services and classes, or offering wellness education and resources the to Backline community.
The information completed in this survey will be reviewed by Backline staff and vetted based on criteria set internally. Those who match the criteria will be added to a public-facing directory for the Backline community.
For more information on our code of ethics for practitioners, please read
this document
.
I acknowledge that I have reviewed and understand the ethical guidelines provided to me, and I agree to uphold the standards, confidentiality requirements, and professional expectations outlined in the policy.
We look forward to learning about you and your work!
Wellness Credentials
LMT (Licensed Massage Therapist)
200 HR- YTT (200 Hour Yoga Teacher Training)
E- RYT- 200 (Experienced Registered Yoga Teacher, 200 hours of training)
E- RYT- 500 (Experienced Registered Yoga Teacher, 500 hours of training)
RN, BSN (Registered Nurse, Bachelor of Science in Nursing)
HNB-BC (Holistic Nurse Baccalaureate Board Certified)
DC (Doctor of Chiropractic)
RH (Registered Herbalist)
RD (Registered Dietitian)
LDN (Licensed Dietitian Nutritionist)
BCHN (Board Certified in Holistic Nutrition)
CNS (Certified Nutrition Specialist)
LCAT (Licensed Creative Arts Therapist)
CD (Certified Doula)
Reiki I
Reiki II
Master Reiki Practitioner
ACE Certified Health Coach
HHP (Holistic Health Practitioner)
NCCAOM Licensed (National Certification Commission for Acupuncture and Oriental Medicine)
Other
Other wellness credentials:
Please list any credentials not listed above.
We understand there are different qualifications for each modality and while the following four questions may seem redundant, please fill them out in a way that is most true for you.
States:
In what states do you practice?.
State (or All States)
License Number: If your modality require a license, please list the license number here.
Training and Experience
Practicing since:
What year did you begin offering wellness services?
Wellness Certifications:
Please list any certifications you hold in your modality. (Please write N/A if this does not apply.)
Wellness Training:
Please tell us about your training, including workshops, training seminars, or classes attended. (Please write N/A if this does not apply).
Trauma-informed training:
Have you received training in trauma-informed care?
We recognize there are diverse healing traditions rooted in Indigenous knowledge taught within intact cultures, outside of a Western frame. If your training aligns more with these lineages, we would appreciate hearing about your background and experiences.
Wellness Offerings & Rates
Location:
Do you offer in-person, virtual sessions, or both?
Offerings:
Please tell us about your specific offerings and the rates for each.
Sliding Scale:
Would you be willing to offer sliding scale rates for your services (digital or physical) to Backline clients?
Please select...
Yes
No
Flexible Hours:
Do you have weekend or evening availability?
Please select...
Yes
No
Maybe
Donated Sessions/Services:
Are you willing to donate a session or service to Backline for social media? (ie. a meditation or series that demonstrates your area of expertise)
Teaching Style/Approach:
Please tell us about your teaching style and/or approach to guiding clients in your modality.
Social Media:
Please share one (or more) social media handle(s) for your wellness practice.
Wellness Business
If your services match our criteria and you are accepted into the database, we will display your business information (name, description of services, link to website) on our public-facing website as part of a directory for the Backline community. Please share the name of your business to be displayed in the directory.
Name:
Please share the name of your business to be displayed in the directory.
Website:
Please share your website for our directory.
Description:
Please give a short description of your services for our the directory (1-3 sentences).
Logo (optional):
Please upload your business logo.
Wellness Directory
Educational Materials:
Do you have educational materials we could link to or spotlight on our website for Backline clients to access?
I
f yes, please share a link to these materials below.
Video
Video:
Please upload a 30-second video introducing yourself to the Backline team. Share a link to a Google file, YouTube, or Vimeo below. This video will be used for the team to get to know you and will not be shared publicly.
If preferred, you can link to an existing piece of content highlighting your work i.e a podcast, educational video, etc.
How did you hear about Backline?
Which conference or professional event?
Which festival or onsite activation?
Which partner organization?
Which press or media source?
If other Backline connection:
If other, please describe the way you heard about Backline:
Music industry experience:
Have you worked previously with individuals in the music industry?
Yes
No
Music industry experience explained:
Please explain your previous work with music industry individuals.
Personal Experience:
Do you have personal experience in the music industry?
Yes
No
Personal experience explained:
Please elaborate on your personal experience.
Genre/Bands:
Please share your favorite genre and band.
Anything else for us to know?
Contact Information