Provider Specialties

 MENTAL HEALTH and ADOA CLINICIANS IN THE WRAPAROUND NETWORK

 Use this form to identify or update clinical specialties and language proficiencies.

  Clinicians declaring a specialty are asked to identify specialties based on current credentials (including licenses) in combination with the following for each identified specialty area: 

  1) additional course work
  2) association membership(s)
  3) additional training / certification
  4) five (5) years full time equivalent experience working with clients in the identified
    specialty area (primary focus of clinical practice during this time) 
 SUPPORTING DOCUMENTATION TO BE MADE AVAILABLE UPON REQUEST.
NOTE:  Typically, clincians would identify no more than 2 to 3 areas of expertise.

Wraparound  Milwaukee enrolled families and case managers can view clinician 
specialty information in the Wraparound Online Resource Guide.

INFORMATION PROVIDED BELOW WILL BE ENTERED UNDER
ALL WRAPAROUND MILWAUKEE NETWORK AGENCIES
WITH WHICH YOU ARE LISTED AS A PROVIDER.

 

First Name             Last Name  
 

Agency Name(s) 

(List the name so of the Wraparound Milwaukee associated agency or agencies where you work.)

 

Phone        Email Address  

Your phone is  needed so we may contact you in the event that we have any questions about the information submitted on this form.

Your email address will be entered in "Synthesis" for so that we can send up Provider Network releated updates and information.

AREA OF PRACTICE:  

 MENTAL HEALTH SERVICES

Yes No        Credential:  

                                                           (Do not include training credentials)   

     AGE RANGES SEEN - Selct one or more of the following:
     Birth to 3   4-11   12-15   16-18    18-25  25-65   Over 65

 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

 AODA SERVICES

Yes No        Credential:     

                                                           (Do not include training credentials)

     AGE RANGES SEEN - Select one or more of the following:
     Birth to 3   4-11    12-15  16-18    18-25  25-65   Over 65 

 

SPECIALITY AREAS (Check the areas that apply to your training and expertise.)

Mental Health and AODA issues commonly treated by trained professionals (such as anxiety or anger management) are not listed as specialties.
Specialty Years Experience Specialty Years Experience
ADHD/ADD  Neuro-Psychology Evals

Art Therapy  

Occupational Therapy
Autism

Occ Ther-Sensory Integration
Canine Therapy Panic Disorder
Child Psychiatry Pediatrician
Couples Therapy Pet Therapy
Dialectical Behavorial Therapy Physical Abuse Victim
Divorce Play Therapy
Domestic Violence PTSD 
Eating Disorders Reactive Attach Dis
Family Therapy Recreation Therapy
Gambling Addiction Sexual Abuse Perpetrator
Gender Identity Issues

Sexual Abuse Victim
Grief/Loss Issues

Teen Pregnancy

HIV/AIDS Related Issues

Terminal Illness

Music Therapy

 Trauma Victim/Witness  
Note:  Mental Health and AODA issues commonly treated by trained professionals (such as anxiety or anger management) will not be listed as specalties.

 Other - Define

 Years Experience

 Other Define 

 

 Years Experience

 
LANGUAGES SPOKEN (fluent)     

American Sign Language
Bosnian

Chinese

French

German

Haya

Hebrew

Hindi

Hmong

Italian

Japanese

Korean

Lao

Polish

Portuguese

Russian

Spanish

Swahili

Thai

Urdu 

 Language - Other

  Identify "other" language
   

  

 

 

 

 

 


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