Apply as a Provider

Identity

First Name*

Last Name*

Email*

Qualifications

Select all that apply. *

LCSW — Licensed Clinical Social WorkerLMFT — Licensed Marriage and Family TherapistLPC — Licensed Professional CounselorPsyD — Doctor of PsychologyPhD — Doctorate in PsychologyMD — PsychiatristLMHC — Licensed Mental Health CounselorCMPC — Certified Mental Performance ConsultantOther

Licensure

Primary license number(optional)

Additional license number (optional)

Insurance Verification

All fields required. Your certificate is stored securely as part of your permanent record.

Insurance carrier name*

Insurance policy number*

Insurance expiration date*

Insurance certificate*

PDF, JPG, or PNG — max 10 MB

Click to upload certificatePDF, JPG, PNG up to 10 MB

Practice Type

Are you applying as an individual provider or for your group practice?*

Experience

How many years of experience do you have providing support to athletes?*

Licensed In

Select the state(s) where you are licensed to practice. *

Licensed in all states (nationwide)

Time Zone

Time Zone*

Matching Information

Help us match you with the right athletes

I am a former athleteSport focus (optional)

Competition levels you work with*

Session format offered*

I am affirming of (optional, select all that apply)

How Did You Hear About Us?

How did you hear about HomeTeam? (optional)

Attestation

Please review and confirm each statement individually. All are required to submit.

1.I confirm the information I've provided is accurate and complete.

2.I confirm I hold the credentials and licenses I've indicated, and they are currently active and in good standing.

3.I am legally authorized to provide services in the state(s) I've indicated.

4.I am not currently subject to any disciplinary action, license suspension, or pending investigation by a licensing board or professional body.

5.I have current professional liability/malpractice insurance.

6.I understand HomeTeam is a matching and scheduling platform, not my employer, and does not provide clinical supervision or crisis response.

7.I will notify HomeTeam promptly if my license status, credentials, or insurance changes.

8.I understand my obligations as a mandatory reporter under applicable state law.

9.I agree to be contacted by HomeTeam about my application.

Type your full legal name as your electronic signature*

Date

June 28, 2026

UTC timestamp recorded on submission.

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