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Provider Onboarding Survey

Step 1 of 6

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This field is for validation purposes and should be left unchanged.

WELCOME TO ORCHARD MENTAL HEALTH GROUP.

As part of our onboarding process, we kindly request your assistance in completing our new provider onboarding form.

This form is essential for us to collect pertinent information for various purposes including onboarding, credentialing, understanding your clinical expertise, and scheduling arrangements. Your prompt completion of this form will greatly facilitate our efforts in ensuring a smooth and efficient integration into our team.

Before you begin, please prepare the following:

  1. A signed copy of the Medicare 855i Form Signature Page. You may either (a.) print and sign TWO (2) copies of the form and mail both copies to Orchard Mental Health Group, Attn: Juliane Schoenherr, 9707 Key West Ave, Ste 100 Rockville, MD 20850, or (b.) Drop off TWO (2) copies of the forms at our Rockville office.
  2. A signed copy of the CAQH Standard Authorization, Release and Consent Form.
  3. An updated copy of your CV/Resume
  4. A copy of your Degree/Diploma (Master or Doctoral)
  5. A Written Bio for your profile. - What do you want potential clients to know about you? For tips on how to write a compelling bio, read this blog post.
  6. A Professional Headshot for your profile*
You may also email your signed CAQH Release form, your updated CV, and diplomas to credentialing@orchardmentalhalth.com. However, any delays can cause credentialing setbacks and delays in your start date.

*= The practice will reimburse up to $50.00 for professional headshots. Sites like https://secta.ai/ are highly recommended. To receive reimbursement please email receipt and picture to hr@orchardmentalhealth.com 

Your prompt attention is much appreciated!

General Provider Information

Please provide preliminary information about yourself.
Name(Required)
Clinical Hours Per Week(Required)
MM slash DD slash YYYY
Location(s) - Select all that apply(Required)

Credentialing

We will use your CAQH username and password to ensure your CAQH profile has all the information our insurance partners need to process your application. We will not alter any existing details, we will only add new entries pertaining to Orchard Mental Health Group. If you forgot your login information, you can reset it here.

To get credentialed, we’ll need to update your CAQH profile with the information you just provided. To make things easy, Orchard Mental Health Group will do this on your behalf.

**IMPORTANT**
  • We require that your CAQH profile includes your 10-year employment/academic history with no gaps. If you do not have 10 years of experience, please list all of your previous experience, thus far.
  • Please upload an UPDATED CV (different from the one you submitted for your employment application). For the purposes of credentialling with our accepted insurance providers, your current employer should read "OMHG/GBCC/Oasis".
    • Max. file size: 128 MB.
    Please ensure that your current employer reads, "OMHG/GBCC/Oasis".
    Education(Required)
    Degree
    Major
    Focus and/or Minor ("N/A" if none)
    Institute
     
    Certifications
    Certification
    Institute
     
    Drop files here or
    Max. file size: 128 MB.
      Consent(Required)
      Attestation(Required)
      Max. file size: 128 MB.
      Please ensure that your profile includes your 10-year (or complete) employment/academic history without any gaps.
      License Number(s)(Required)
      License #
      State
      Expiration Date (mm/yyyy)
       
      Please list your license number(s) for all States you currently hold an ACTIVE license.

      Provider Schedule

      Please provide your working schedule. This will help our team to build out your calendar template and client care coordinators to start scheduling new clients
      Availability (Eastern Time)(Required)
      Days of the Week - please list individually
      Time(s) (Ex. "8am-12pm, 7-9pm")
      Breaks - time(s) and duration ("30 min lunch break, 12-12:30pm")
       

      Provider Treatment Preference

      Please share information about the age groups, treatment specialties and modalities you work with. This will help our team with the matching process.
      Age(s) Served - Select all that apply(Required)
      Services(Required)
      Types of Therapy - Select all that apply(Required)
      Modalities- Select all that apply(Required)
      More modalities you would like to add
      Approaches(Required)
      More approaches you would like to add(Required)
      Areas of Expertise(Required)
      More areas of expertise you would like to add(Required)
      Special experience working with LGBTQ+ populations
      Special experience working with populations
      Other racial/ethnic background(s)
      You can write this in either first or third person. If in third person, please specify how you would like to be referred ("About Dr. Singer" vs. "About Carrie").
      Languages - if applicable
      Please include any language(s) in which you have proficiency/feel confident providing services in.
      Max. file size: 128 MB.
      Higher resolution is ideal. Please note that this will be cropped to be square.

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      contact@orchardmentalhealth.com | © Copyright Orchard Mental Health Group 2025

      Need to Cancel or Reschedule an Appointment?

      Please note we have a 48-business-hour cancellation policy. For a full list of our current cancellation and no-show fees, please visit our Billing Page.

      In crisis or need immediate help?
      Call 988 for the Suicide & Crisis Lifeline, or go to your nearest Emergency Room.

      To cancel or reschedule an existing appointment, you may:

      • Complete the form below, or

      • Call us during business hours at 240-750-6467

      Cancel/Reschedule an Appointment

      This field is for validation purposes and should be left unchanged.
      Your Name(Required)
      Client's Name(Required)
      If you don't know your clinician's name, please leave this blank.
      You may request a new appointment using this form.
      Therapy/Counseling Acknowledgement of Fees(Required)
      We charge a fee because whenever a session is canceled without adequate notice, we are unable to fill this time slot by offering it to another current client, a client on the waitlist, or a client with a clinical emergency.
      First-Time Medication Management Acknowledgement of Fees(Required)
      We charge a fee because whenever a session is canceled without adequate notice, we are unable to fill this time slot by offering it to another current client, a client on the waitlist, or a client with a clinical emergency.
      Follow-Up Medication Management Acknowledgement of Fees(Required)
      We charge a fee because whenever a session is canceled without adequate notice, we are unable to fill this time slot by offering it to another current client, a client on the waitlist, or a client with a clinical emergency.
      Testing/Evaluation Cancellation Acknowledgement of Fees(Required)
      We charge a fee because whenever a session is canceled without adequate notice, we are unable to fill this time slot by offering it to another current client, a client on the waitlist, or a client with a clinical emergency.
      MM slash DD slash YYYY
      Time of the Appointment (Eastern Time)
      :
      If you don't remember, you can leave this blank.

      Reschedule an Appointment

      Please note that our team cannot guarantee your preferred time/date. We will try our best to accommodate. Our scheduling team will be in touch with you ASAP.
      MM slash DD slash YYYY
      Preferred Time (Eastern Time)
      :
      Please note that our in-office clinicians may only take visits at their designated office.
      Scheduling Acknowledgement(Required)

      Need to Cancel or Reschedule an Appointment?

      Please note we have a 48-business-hour cancellation policy. For a full list of our current cancellation and no-show fees, please visit our Billing Page.

      In crisis or need immediate help?
      Call 988 for the Suicide & Crisis Lifeline, or go to your nearest Emergency Room.

      To cancel or reschedule an existing appointment, you may:

      • Complete the form below, or

      • Call us during business hours at 240-750-6467

      Please be aware that we do have a 48-business-hour cancellation policy. For a full list of our current cancellation/no-show fees, please visit our Billing Page
      ***Are you in crisis or in need immediate help?
      Please call 988 or go to your nearest ER.***

      For Current Clients: Schedule an Appointment

      This field is for validation purposes and should be left unchanged.
      If you are unsure whether your information is on-file, please enter your contact information, so we can confirm with you. If you are a new client, please use our Initial Appointment Request Form. Thank you!

      Request an Appointment

      Welcome back! Before we get started, we may need to confirm that we have your info on file...

      Your Name(Required)
      Client's Name(Required)
      Acknowledgement(Required)

      Thank you for starting this journey with OMHG.

      This appointment scheduler is for returning clients. As a new client, there are additional details you will need to submit to help OMHG get you started. Please use our Initial Apppointment Request Form. Thank you!

      Request an Appointment

      Welcome back!

      Your Name(Required)
      Client's Name(Required)
      If you don't have a preferred clinician, please leave this blank.
      MM slash DD slash YYYY
      Preferred Time (Eastern Time)
      :
      Please note that our in-office clinicians may only take visits at their designated office.
      Scheduling Acknowledgement(Required)

      Orchard Mental Health Group is happy to accept referrals!

      Referral Form

      This field is for validation purposes and should be left unchanged.
      Your First Name(Required)
      Your Last Name
      Contact(s)
      In order for us to reach out to them, we will need your referral's name, as well as any contact info you can share. You can list multiple people, if you would like!
      Their Name
      Their Phone Number
      Their Email
       
      You can tell us more about the individual(s), what service(s) you're recommending them for, or even just ask us a question!

      We thank you for taking an active role in someone’s mental well-being, and for helping us grow.