User Registration - ARISE Alliance Institute

1Account Information

2Address

3Emergency Contact

4Eligibility

5License

6Clinical Supervisor

7Business Details

Hidden

Contact Type

Hidden

Salesforce Account Name

Hidden

Salesforce Account Record Type ID

Name*

First Last

Email*

Phone*

Job Title

Profession

Street Address*

City*

State*

ZIP Code*

Emergency Contact Name

Emergency Contact Phone #

Emergency Contact Email

Relationship to Emergency Contact

Have you COMPLETED at least one of the following?

Master’s Degree in Counseling

Master’s Degree in Social Work

Master’s Degree in Mental Health Counseling

Master’s Degree in Psychology

Master’s Degree in Marriage and Family Therapy

Master’s Degree as a Psychiatric Nurse Practitioner

Medical Degree in Psychiatry

None of the above

Do you currently hold any type of mental health related state licensure (provisional or independent)?

Yes

Does your mental health related license allow you to practice clinical work independently (without supervision) in your state of licensure?

Yes

Does your mental health related license allow you to practice clinical work UNDER SUPERVISION in your state of licensure?

Yes

Congratulations, you qualify for the non-accredited learner track and are eligible to take T3 and/or Introduction to CMI.

Profile Opt In

I would like for my information to be displayed on the ARISE website as a licensed clinical provider

I agree to display my information

State of Primary Licensure*

Type of License*

License Abbreviation*

License #*

Upload Copy of License*

Max. file size: 100 MB.

Please upload a copy of your provisional, intern, or non-independent license and provide your license information. If you are licensed in multiple states, please use your state of primary practice.

Please be advised that verification of active supervision is required to qualify for this course.

Clinical Supervisor's Name*

Clinical Supervisor's Email*

Clinical Supervisor's Phone

Business Name*

Business Phone*

Business Street Address*

Business City*

Business State*

Business ZIP Code*