Postpartum Resource Center of New York

State-wide Helpline: Toll free: 855-631-0001

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Postpartum Resource Center of New York's
Perinatal Mood and Anxiety Disorder
State-wide Resource Directory
Online Application

To be considered for inclusion in the Directory, kindly return this form completed with the supporting documentation requested. Your application will be reviewed and you will be notified of our decision. Inclusion in the Directory is not an endorsement by the Postpartum Resource Center of New York, Inc. of your business or services.

Please complete all fields below and then submit when you are done. The asterisk (*) notes fields that are required to be completed before you may submit your application.

If you have any questions, please feel free to contact us here.

You may also download the Directory application below (pdf) and mail it completed to us with supporting documentation.

PRCNY – PMAD State-wideResource Directory Application

PRCNY – PMAD State-wide
Resource Directory Application

Provider Type *

Psychiatrist
Psychologist
Social Worker
Counseling Professional
Agency
Support Group
Other – please specify below

If "Other", please specify here.

Provider Name *

Credentials:

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Phone *

Fax

Email *

Website

Languages (including sign)

In addition to English, please list any languages you speak and/or read and write.

Other information

Please include any other relevant information here.

Payment Accepted *

Private Insurance
Self-Pay
Medicaid
Sliding Scale
Other

If "Other", please explain below.

If your payment option is "Other", please explain here.

Prescription of Medication – Can you prescribe? *

Yes
No

Whether you prescribe or not, do you have an MD backup? *

Yes
No

Are you licensed for your profession? *

Yes
No

If yes, please upload a copy of your license below.

Professional License

Your file will be uploaded once you complete the form and submit the application.

Has you license every been suspended or revoked? *

Yes
No

If yes, please explain below.

Please use space above to explain any license suspension or revocation.

Education/Degrees: *

Certifications:

Additional Training (may attach your CV)

CV or Resume

Your file will be uploaded once you complete the form and submit the application.

What is your area of expertise? *

What type of practice are you in (private, agency, etc.)? *

Please describe the type of services or treatments you provide (or attach your brochure): *

Your business brochure

Your file will be uploaded once you complete the form and submit the application.

Approximately how many clients have you treated for perinatal mood disorders? *

Please explain, according to your understanding, the difference between perinatal mood disorder OCD and postpartum psychosis. *

In your treatment of patients with a perinatal mood disorder, do you incorporate family involvement, support groups, prescription medications, hormone testing, nutrition, exercise and/or spirituality? *

Yes
No

If yes, please note which ones:

Have you ever utilized the services offered by the Postpartum Resource Center of New York? *

Yes
No

Are you a member of the Postpartum Resource Center of New York? *

Yes
No

Are you a member of Postpartum Support International? *

Yes
No

Please provide us with any other information you feel would be helpful and relevant to your application. *

Thank you for your application to the Postpartum Resource Center of New York, Inc.'s Perinatal Mood Disorders Resource Directory. Your application will be reviewed and we will notify you of our decision.

I understand that inclusion in the Directory is not an endorsement by the Postpartum Resource Center of New York, Inc. of my business or services.

Name *

First

Last

Date *

Name

Postpartum Resource Center of New York
Perinatal Mood and Anxiety Disorders:
Finding the Help you Need.
Serving New York State Families Since 1998

In New York State please email us or call

State-wide Helpline:
Toll free: 855-631-0001
Office: 631-422-2255
Hablamos Español

For help outside of New York State and the United States,
please contact the Postpartum Support International.

The information on this site is not intended to diagnose
or treat any medical or psychological condition.
Please consult your doctor for individual advice
regarding your own situation.

The Postpartum Resource Center of New York, Inc.
is a not-for-profit, 501(c)(3) tax-exempt organization.
Tax ID# 11-3449880
All Rights Reserved. Copyright ©1998-2022

All content ©1998-2023 Postpartum Resource Center of New York

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