Provider Information Update
Print Form to Fax
Use this form to submit your request to be included in our provider referral database.
To submit the form by fax:
1. Fill in the information on both pages of this form.
2. Click on the Print Form to Fax button at the top of this page.
3. You must sign the form to be considered for inclusion in our database.
4. Fax the completed and signed form to the number listed at the right.
Please contact us if you have any questions.
UNCW Counseling Center
601 South College Road
Wimington, NC 28403
Phone: 910-962-3746
Fax: 910-962-7124
www.uncw.edu/counseling
Agency
Provider
Title
First Name
Last Name
Address 1
Address 2
City
State
Zip Code
Enter numbers only, no dashes or parentheses.
Work Phone
Mobile Phone
Fax
Email Address
Website
Credentials
Other / Additional
American Sign Language (check for yes)
Language(s)
Fees and Insurance (check all that apply)
Offers reduced fees or sliding scale
Medicaid
Aetna
Medicare
BCBS
Tricare
CIGNA
United Healthcare
Medcost
Other(s)
Check all that apply
Psychiatrist on staff
Within 1 mile of campus
On a bus route
Accessible to individuals with disabilities
I would like to volunteer in case of a large- scale campus disaster or
emergency.
I have psychological first aid training.
I do not have psychological first aid training.
I would be interested in participating in training or professional
development programs related to student mental health.
Services
Check all that apply.
Individual Counseling
Types of groups
Couple Counseling
Group Counseling
Family Counseling
Other programs
Long-term Counseling
Areas of specialization or special interest.
Addictions
Grief / Bereavement
Physical Abuse / Violence
ADD / ADHD
HIV / AIDS
Rape / Sexual Assault
Adjustment / Transitions
Hypnosis
Relationship Concerns
Adjustment to disability
Identity / Developmental Concerns
Schizophrenia / Psychoses
Anger / Emotion Management
LGB Concerns
Sex / Sexuality
Anxiety
Learning Disabilities
Sexual Abuse
Autism Spectrum
Life Coaching
Spirituality
Body Image / Eating Disorders
Men's Concerns
Stress / Relaxation
Chronic Health / Pain Concerns
Military / Veteran Concerns
Substance Abuse
Cultural / Diversity Concerns
Mind / Body Issues
Transgender Concerns
Depression
OCD
Trauma / PTSD
Forensics
Personality Disorders
Women's Concerns
Other areas of specialization or interest
Testing and assessment
ADD / ADHD
Forensic
Personality
Cognitive / IQ
Learning Disabilities
Substance
Fitness for Duty
Neuropsychological
Threat Assessment
Brief description
of your practice
Other
Additional
Information
I attest that the information provided on this form is accurate.
Signature
Date