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

Birthdate

City

State

Country (if international)

I am a:

ClinicianWellness ProviderBoth (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?

YesNo

Free Consultation: Do you offer free consultation calls?

YesNo

Licensed: Are you a licensed clinician?

YesNoProvisionally 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.

YesNo

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?

YesNo

Superbill: If you do not accept insurance, are you able to provide Superbills?

YesNo

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?

YesNo

Lowest Fee: What is your lowest possible fee?

Accepted payment methods: Please select all.

CCPayPalVenmoCash

Specific populations: Which specific populations do you feel particularly equipped to serve?

LGBTQIA+BIPOCVeteransActive Duty MilitaryNeurodivergenceSurvivors of Trauma and AbuseImmigrants and RefugesOlder Adults and Geriatric ClientsChronic Illness or DisabilityLow-income or Housing-insecure clientsOther

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 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?

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)

Flexible Hours: Do you have weekend or evening availability?

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? If 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?

YesNo

Music industry experience explained: Please explain your previous work with music industry individuals.

Personal Experience: Do you have personal experience in the music industry?

YesNo

Personal experience explained: Please elaborate on your personal experience.

Genre/Bands: Please share your favorite genre and band.

Anything else for us to know?

Before you click Submit, please note:

We’ve introduced a new and improved Case Management System to help us better coordinate care, streamline referrals, and expand access to support for music industry professionals and their families.

After submitting this form, you’ll receive an email to schedule a call with a member of Backline’s Clinical Team. The scheduling link will also appear on the screen once you submit.

If you do not receive the email, are experiencing any issues with the form, or have any questions at all, please reach out to hello@backline.care for support.

Contact Information