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Peace Begins at Home

ALTUS

HOME COUNSELING AND BEHAVIORIAL SERVICES, LLC

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Welcome to Altus!

New Contractor Form

Hello! Welcome to Altus! This form will help us get you onboarded.

Email*

Start Date*

What date would you like to start?

Name*

Degree Attained*

License Held*

Address

Country/Region*

Address*

City*

Zip / Postal code*

Phone*

Enter the phone number you would like admin to contact you at.

NPI Number*

CAQH Number*

Enter CAQH Login and Password if you would like us to update it for you.

Upload a copy of your state ID.*

Upload a copy of your license to practice.*

Upload a copy of your resume.*

Preferred treatment population*

All Ages

Individuals

17 and under (all adolescents)

Couples

18 and up (all adults)

Families

18 though 30 (young adults)

Substance Abuse

30 and up (all adults)

Other

Upload a headshot.*

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Upload a copy of your liability insurance.*

Click here for IRS form W9 ---->

Upload you completed W9 form.*

Upload the filled out and signed contractor agreement.*

What are you interested in learning more about (for example, trauma modalities, couples, substance abuse, mood disorders, personality disorders, etc)?*

Email for clients*

An email address for clients to contact you.

Phone number for clients*

Phone number for clients to contact you.

Cash rate for individuals*

Cash rate for couples*

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Altus Home Counseling and Behavioral Services, LLC

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Contact

(313) 200-4626
appointments@altuswellbeing.com

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