Mind Over Mood Initiative Partnership Determination Survey Name* First Last Credentials* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxEmail* If applicable, what is the name of the independent group practice you are part of? Are you an independent practice clinician in Connecticut?Choose one:Yes, full time private/small independent group practiceYes, part time private/small independent group practiceNo, I'm in the planning stagesNo, I work for an agency-based practiceOtherIf other, please specify: Are you credentialed as a Husky behavioral health provider?Choose one:Yes, and I've billed Husky successfullyYes, but I haven't billed Husky yetNo, I am currently in the processNo, not yetHave you ever provided psychotherapy in families' homes?Choose one:Yes, I have past and current home-based tx experience and trainingYes, I have past home-based tx experience and trainingYes, but limited experience providing services in the homeNo, but I am willing to expand my practice to include home-based txOtherIf other, please specify: Which of the following areas are you be willing to provide home-based services in? Danbury Hartford Meriden Middletown New Britain New London Norwalk Norwich Putnam Stamford/Greenwich Torrington Waterbury Please specify what towns you are willing to provide home-based services in: Do you provide psychotherapy in Spanish? Yes No Specify other practicing language: Tell us about your experience working with pregnant and postpartum mothers experiencing depression or anxiety?What is your experience working with early childhood home visitation?Check all that apply. I have worked in home-based prevention services I have worked in home-based clinical services I have worked in child welfare services I have worked in early intervention services I have worked in collaboration with home visitation services I have no experience working with home-based early childhood services Other If other, please specify: What is your training and experience treating perinatal mood and anxiety disorders?Choose one:I have formal training and experience in treating PMADsI have formal training but limited experience in treating PMADsLimited training and experience treating these disordersMy practice specializations include: What is your training and experience in dyadic work?Choose one:I have formal training and experience working with parents and infants/young childrenI do not have formal training but I have worked with parent-infant dyadsI am hoping to learn more about attachment-based practice/working with mother-child dyadsOtherIf other, please specify: What is your hope and expectation for client referrals?Choose one:I hope/expect a steady stream of referrals from the NFN site I am partnered withI hope/expect one or two active cases at a time from my partnered NFN siteI have no specific hope/expectation for referrals but want to be in a partnering role with the NFN programI have no client openings at this timeHow would you describe your referral availability?Choose one:I often have multiple openingsI often have one or two available openingsI am often at capacity and have a waiting listI am often full during the day but have evening and weekend availabilityI only offer my practice evenings and weekendsOtherIf other, please specify: PhoneThis field is for validation purposes and should be left unchanged.