Geisinger Health Plan Behavioral Health Professional Services Questionnaire Instructions

Check this box if your practice accepts children aged 12 years or younger.

Check this box if your practice accepts adult patients between ages 18 and 64.

Check this box if your practice accepts adolescent patients aged 13 through 17.

Check this box if your practice accepts geriatric patients aged 65 or older.

Check this box if you (or someone on your staff) can communicate with patients using American Sign Language.

Check this box if you (or someone on your staff) can communicate with patients in Mandarin.

Check this box if you (or someone on your staff) can communicate with patients in French.

Check this box if you (or someone on your staff) can communicate with patients in Spanish.

Check this box if you (or someone on your staff) can communicate with patients in German.

Check this box if you can communicate with patients in a language not listed, and write that language in the provided space.

Enter any other language(s) you can communicate with patients in that are not listed on the form (separate multiple languages with commas). Fill only if 'Other' is 'Yes'.

Check this box if your group offers a Partial Hospitalization Program (PHP) for children (12 or younger) to treat eating disorders (ED).

Check this box if your group offers an Intensive Outpatient Program (IOP) for children (12 or younger) to treat eating disorders (ED).

Check this box if your group offers a Partial Hospitalization Program (PHP) for children (12 or younger) to address general mental health disorders and concerns (MH).

Check this box if your group offers an Intensive Outpatient Program (IOP) for children (12 or younger) to address general mental health disorders and concerns (MH).

Check this box if your group offers a Partial Hospitalization Program (PHP) for children (12 or younger) to treat substance use disorders (SUD).

Check this box if your group offers an Intensive Outpatient Program (IOP) for children (12 or younger) to treat substance use disorders (SUD).

Check if your group offers a Partial Hospitalization Program (PHP) for eating disorders to patients age 65 and older.

Check if your group offers an Intensive Outpatient Program (IOP) for eating disorders to patients age 65 and older.

Check if your group offers a Partial Hospitalization Program (PHP) for general mental health disorders and concerns to patients age 65 and older.

Check if your group offers an Intensive Outpatient Program (IOP) for general mental health disorders and concerns to patients age 65 and older.

Check if your group offers a Partial Hospitalization Program (PHP) for substance use disorders to patients age 65 and older.

Check if your group offers an Intensive Outpatient Program (IOP) for substance use disorders to patients age 65 and older.

Check this box if you would treat clients referred for abuse, assault, trauma, or PTSD.

Check this box if you would treat clients referred for ADD or ADHD.

Check this box if you would treat clients referred for addiction or substance use disorders.

Check this box if you would treat clients dealing with adoption-related issues.

Check this box if you would treat clients with affective (mood) disorders.

Check this box if you would treat clients with AIDS/HIV-related psychosocial or mental health issues.

Check this box if you would treat clients with anorexia nervosa and/or ARFIDS.

Check this box if you would treat clients with anxiety disorders.

Check this box if you would treat clients with antepartum, pregnancy-related, or post-partum issues.

Check this box if you would treat clients with autism spectrum disorders.

Check this box if you would treat clients with bipolar disorder.

Check this box if you would treat clients experiencing cancer-related issues.

Check this box if you would treat clients with compulsive gambling behaviors.

Check this box if you would treat clients with co-occurring disorders (e.g., mental health and substance use conditions).

Check this box if you would treat clients with COVID-related mental health or psychosocial issues.

Check this box if you would provide treatment for clients needing chronic pain management.

Check this box if you would treat clients experiencing cultural or ethnic-related issues.

Check this box if you would treat clients with depression.

Check this box if you would treat clients with developmental disorders.

Check this box if you would treat clients with Disruptive Mood Dysregulation Disorder and/or Oppositional Defiant Disorder.

Check this box if you would treat clients dealing with divorce or blended family issues.

Check this box if the referred person has a history of domestic violence and/or symptoms or diagnosis of post-traumatic stress disorder (PTSD).

Check this box if the referral involves both intellectual or developmental disabilities and a co-occurring mental health condition.

Check this box if the referred person has an eating disorder diagnosis or clinically significant disordered eating behaviors.

Check this box if the referral is for gender transition support, gender identity concerns, or related counseling needs.

Check this box if the referred person has hearing loss or impairment that affects service needs or accommodations.

Check this box if the referral is for issues related to sexual orientation, gender identity, or other LGBTQ+ specific concerns.

Check this box if the referral concerns issues commonly experienced by men that require targeted support or counseling.

Check this box if the referred person has a diagnosis of obsessive-compulsive disorder (OCD) or prominent OCD symptoms.

Check this box if the referral is for pain management with a psychiatric focus (e.g., pain-related psychiatric care).

Check this box if the referral is for pain management with a psychological/behavioral focus (e.g., pain coping, pain psychology).

Check this box if the referred person has a diagnosed personality disorder or personality-related treatment needs.

Check this box if the referral involves psychotic symptoms or diagnoses such as schizophrenia or schizoaffective disorder.

Check this box if the referral concerns Reactive Attachment Disorder or attachment-related treatment needs.

Check this box if the referred person is experiencing recent trauma reactions or acute stress related to a recent traumatic event.

Check this box if the referral is for assessment or treatment of sexual dysfunction or related sexual health concerns.

Check this box if the referred person has a history of sexual offending that impacts treatment planning or risk management.

Check this box if the referral involves somatoform or somatic symptom disorders where physical symptoms are related to psychological factors.

Check this box if the referral concerns women-specific issues (e.g., reproductive mental health, gender-based concerns) requiring targeted care.

Check this box if the referred person has Tourette’s syndrome or tic disorders that should be addressed in treatment.

Check this box if the referral is for a treatable condition not listed above and provide the specific condition in the text field or notes.

Check this box when the referral condition is not listed elsewhere and you will specify the condition in the accompanying text field.

Enter any other treatment condition or referral reason not listed above as a short descriptive phrase. Fill only if 'Other (specify)' is 'Yes'.

Enter the practitioner's full name as it should appear in provider listings.

Enter the provider's professional credentials or licensure (for example: MD, DO, LCSW, PsyD).

Enter the provider's National Provider Identifier (NPI) number assigned to the practitioner.

Enter the provider's practice street address including city, state, and ZIP code.

Enter the county where the provider's practice location is located.

Enter the name of the practice, clinic, or provider group with which the practitioner is affiliated.

Enter the primary phone number to be published for this provider (include area code).

Check this box if you offer Acceptance and Commitment Therapy as a service.

Check this box if you offer Grief, Loss, or Separation Counseling as a service.

Check this box if you offer Cognitive Behavioral Therapy (CBT) as a service.

Check this box if you provide Neuropsychological Testing as a service.

Check this box if you provide couples or marital therapy services to clients.

Check this box if you offer faith-based or spiritually integrated counseling services.

Check this box if your organization offers court-ordered evaluations as a service.

Check this box if your organization provides psychiatric medication management services.

Check this box if your practice offers crisis intervention services (immediate or short-term emergency mental health support) to clients.

Check this box if your practice provides psychodynamic psychotherapy (therapy focused on unconscious processes and early life experiences).

Check this box if your organization provides forensic evaluations or disability assessment services.

Check this box if your organization offers psychological testing services.

Check this box if your practice/organization offers Dialectical Behavioral Therapy (DBT) as one of its services.

Check this box if your practice/organization provides sexual offender treatment services.

Check this box if your practice offers Early Intensive Behavioral Intervention (EIBI) services.

Check this box if your practice provides services via telemedicine or telehealth.

Check this box if your practice or facility offers electroconvulsive therapy (ECT) as a treatment option.

Check this box if your practice or facility offers transcranial magnetic stimulation (TMS) as a treatment option.

Check this box if you offer esketamine treatment services to clients/patients.

Check this box if you provide trauma-informed psychotherapy services such as Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE).

Check this box if the provider offers Eye Movement Desensitization and Reprocessing (EMDR) therapy.

Check this box if the provider offers veteran-specific services related to post-deployment, reintegration, or PTSD.

Check this box if you provide ADHD/ADD diagnostic testing, evaluation, or treatment services.

Check this box if you offer group psychotherapy or therapy in a group format.

Check this box if your organization offers family therapy services as listed (therapeutic services provided to families or family members).

Check this box if your organization provides IBHS (Intensive Behavioral Health Services) for individuals requiring intensive, community- or home-based behavioral health supports.

Check this box if your organization offers gender reassignment assessment services.

Check this box if your organization provides PIBHS (Child & Adolescent Intensive Behavioral Health Services).

Check this box if your practice offers addiction, recovery, or relapse prevention counseling services.

Check this box if your practice offers individual psychotherapy services.

Check this box if your practice offers ambulatory (outpatient) alcohol detoxification services.

Check this box if your practice provides in-home treatment or home visit services specifically for geriatric patients.

Check this box if your organization offers ambulatory substance use detoxification services, including detox for opiate dependence.

Check this box if your organization provides Interpersonal Psychotherapy (ITP) as a treatment option.

Check this box if your organization offers anger management services or programs.

Check this box if your organization provides medication-assisted treatment specifically for alcohol use disorder (AUD).

Check this box if your practice offers Applied Behavioral Analysis (ABA) and related behavioral services.

Check this box if your practice provides Medication Assisted Treatment for Substance Use Disorder (SUD).

Check this box if your organization offers bariatric assessment services.

Check this box if your organization provides methadone maintenance treatment for opioid use disorder (OUD).

Check this box if your organization offers behavioral modification services or programs.

Check this box if your organization provides medication-assisted treatment specifically for pregnant women.

Check this box if your group offers a Partial Hospitalization Program (PHP) for adolescents (ages 13–17) to treat eating disorders.

Check this box if your group offers an Intensive Outpatient Program (IOP) for adolescents (ages 13–17) to treat eating disorders.

Check this box if your group offers a Partial Hospitalization Program (PHP) for adolescents (ages 13–17) for general mental health disorders and concerns.

Check this box if your group offers an Intensive Outpatient Program (IOP) for adolescents (ages 13–17) for general mental health disorders and concerns.

Check this box if your group offers a Partial Hospitalization Program (PHP) for adolescents (ages 13–17) to treat substance use disorders.

Check this box if your group offers an Intensive Outpatient Program (IOP) for adolescents (ages 13–17) to treat substance use disorders.

Enter the signer's signature (handwritten or typed) to affirm the items identified above.

Enter the date the signer completed or signed this affirmation.

Enter the signer's email address for contact regarding this affirmation.

Enter the signer's role or relationship to the practice (for example: owner, manager, practitioner, employee).

Enter the signer's fax number, including country and area codes if applicable.

Check this box if you specialize in diagnosing and treating eating disorders.

Check this box if you specialize in treating obsessive-compulsive disorder (OCD).

Check this box if you specialize in assessment or treatment of individuals on the autism spectrum.

Check this box if you specialize in treating addiction or substance use disorders.

Check this box if you provide specialized services for chronic pain management.

Check this box if you specialize in treating PTSD or trauma-related conditions.

Check this box if you specialize in caring for individuals with co-occurring intellectual disability and mental health conditions.

Check this box if you provide specialized services addressing LGBTQ+ mental health and related issues.

Check this box if your group offers a Partial Hospitalization Program (PHP) for adults ages 18–64 to treat eating disorders (ED).

Check this box if your group offers an Intensive Outpatient Program (IOP) for adults ages 18–64 to treat eating disorders (ED).

Check this box if your group offers a Partial Hospitalization Program (PHP) for adults ages 18–64 for general mental health disorders and concerns (MH).

Check this box if your group offers an Intensive Outpatient Program (IOP) for adults ages 18–64 for general mental health disorders and concerns (MH).

Check this box if your group offers a Partial Hospitalization Program (PHP) for adults ages 18–64 to treat substance use disorders (SUD).

Check this box if your group offers an Intensive Outpatient Program (IOP) for adults ages 18–64 to treat substance use disorders (SUD).