Welcome to LifeStance Health!

We’re glad to have you and we can’t wait to get to know you better. Your photo and bio will be featured on our website as well as other online profiles that generate referrals. Feel free to skip any questions you’d prefer not to answer or expand further on points you think would be helpful for a client to know about you. You may also forward bios from previous positions to IL-Marketing@LifeStance.com. When your LifeStance bio is complete, you will receive a draft via e-mail and have the opportunity to edit before posting.

We also included additional fields and document upload requests needed to initiate the credentialing process and to add you to all of our insurance networks. Please provide this information as soon as possible.

We also require a profile photo using the LifeStance guidelines featured here. If you are unable to take a new photo using LifeStance guidelines, please upload a temporary photo until we are able to take a new photo that aligns with the others on our website.

If you have any questions, please contact IL-Marketing@LifeStance.com.

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  • List Undergraduate School Name, Address (Street/City/state/Zip), Phone Number, Start Date, End Date, Degree Earned
  • List Graduate school name, Address (Street/City/state/Zip), Phone number, Start date, End date, Degree earned, Department Chair/Program Director Name (If Known), Department Chair/Program Director Phone (if known), Department Chair/Program Director Email (If known)
  • Drop files here or
    Accepted file types: pdf, jpeg, png.
  • List Facility/Program Name, Address (Street/City/state/Zip), Phone number, Start Date, End Date, Program Director/Supervisor Name, Program Director/Supervisor Title, Program Director/Supervisor Phone (if available), Program Director/Supervisor Email (If available)
  • License TypeLicense NumberLicense Issue DateLicense Exp Date 
  • Drop files here or
    Accepted file types: pdf, jpeg, png.
  • Visit this website to reset your password if required: https://nppes.cms.hhs.gov/#/
  • Credentialing

    Our National Credentialing Team will be managing your credentialing process at LifeStance! The team will keep your CAQH account updated, complete any required attestations and submit all applications to our over 90+ different insurances on your behalf. Many of our insurance payors have allowed us to panel our under-licensed clinicians (LPC/LSW/AMFT) so we ask all of our providers, licensed at any level, to complete all requested information sections in this form and complete the Credentialing Authorization Form sent to you through DocuSign separately.
  • To retrieve your login information, visit https://proview.caqh.org/Login/Index?ReturnUrl=%2f or call CAQH support at 1-888-599-1771 To create a new account: https://proview.caqh.org/PR/Registration
  • Psychology Today or Other Online Web Profiles

    LifeStance will manage the Psychology Today Profiles for all Full Time Employees for the first 90 days and assume the responsibility of payment to help fill your schedule up. If you are interested in this benefit, please provide your username and login information below:
  • If you do not already have an account active, one will be created for you by our marketing team.
  • Certifications

  • Upload certificate here if applicable
    Drop files here or
    Accepted file types: pdf, jpeg, png.
  • Upload certificate here if applicable
    Drop files here or
    Accepted file types: pdf, jpeg, png.
  • Upload certificate here if applicable
    Drop files here or
    Accepted file types: pdf, jpeg, png.
  • Upload certificate here if applicable
    Drop files here or
    Accepted file types: pdf, jpeg, png.
  • Upload certificate here if applicable
    Drop files here or
    Accepted file types: pdf, jpeg, png.
  • List Medicare ID#/PTAN # and Medicaid ID #. We do not currently accept new patients with Medicaid plans, but do need your Medicaid number on record if you have one assigned. Can put N/A if you do not have one.
  • Getting to Know

    We want our intake team to have the most accurate picture of who you are so we can make the BEST clinical matches for you and keep you as productive and filled up with clients as you desire to be. Please provide the below info regarding client populations you serve.
  • Check all you are comfortable taking referrals for:
  • This list is used by intake to filter available therapists in the matching process. For issues you don’t select, a client that calls with that presenting issue will NOT be placed with you.
  • Your photo and bio will be featured on our website as well as other online profiles that generate referrals. Upload your Bio Here (if already created -if not, just skip and we’ll create a draft for your review based on your previous answers)
    Drop files here or
    Accepted file types: jpeg, png.
  • Drop files here or
    Accepted file types: jpeg, png.
  • List First and Last Name, Credentials / License type (LPC/LCSW etc), Title/Role/Degree, Length of time known, Phone, Fax, and Email Address
  • List First and Last Name, Credentials / License type (LPC/LCSW etc), Title/Role/Degree, Length of time known, Phone, Fax, and Email Address
  • List First and Last Name, Credentials / License type (LPC/LCSW etc), Title/Role/Degree, Length of time known, Phone, Fax, and Email Address
  • Must include the following: 1. LifeStance Health added as current employer 2. All start/end dates formatted for all sections (mm/yyyy) 3. Must list at least five years of employment history (or from date of licensure if less)
    Drop files here or
    Accepted file types: pdf.
  • o Please note any gaps in work history and reason for the gap. o Example reasons may include “employment seeking, return to school, Home with children ect
  • List Board Certification Date, Medical School Address (Street/City/state/Zip), Phone number, Start Date, End Date, Degree earned
  • Drop files here or
    Accepted file types: pdf, jpeg, png.
  • Drop files here or
    Accepted file types: pdf, jpeg, png.
  • List Residency Program Name, Address (Street/City/state/Zip), Phone Number, Start Date, End Date, Degree Earned
  • List Fellowship Program, Address (Street/City/state/Zip), Phone Number, Start Date, End Date, Degree Earned
  • Mandated Reporter Training

    Illinois licensed Clinicians (including physicians) are considered “mandated reporters” who must notify the Department of Children and Family Services (DCFS) when there is reasonable cause to believe that a child may be abused or neglected. All mandated reporters, including physicians, must complete DCFS mandated reporter training under the Abused and Neglected Child Reporting Act, effective January 1, 2020 and is required once every 6 years after that. DCFS TRAINING LINK: https://mr.dcfstraining.org/UserAuth/Login!loginPage.action;jsessionid=28B4946D55E9FD5D2F428D1CB63785C2
  • Drop files here or
    Accepted file types: pdf, jpeg, png.
  • Drop files here or
    Accepted file types: pdf, jpeg, png.
  • Upload additional liability insurance you plan to maintain. *This is not required. You’re covered by LifeStance, but we need a copy of other policies for Credentialing purposes.
    Drop files here or
    Accepted file types: pdf.
  • Additional EAP Qualifications

    Please Check Yes or No to the EAP Qualification Fields Below