Provider Specialties

MENTAL HEALTH and ADOA CLINICIANS IN THE WRAPAROUND NETWORK

Use this form to identify or update clinical specialties and language proficiencies.

Clinicians declaring a specialty are asked to be prepared to submit documentation that supports:
additional course work, training, certification, association membership(s) or five (5) years full time equivalency
experience related to an identified speciality.

Wraparound Milwaukee enrolled families and case managers can view clinician specialty information in the Wraparound Online Resource Guide.

AODA AND MENTAL HEALTH CLINICIAN INFORMATION

INFORMATION PROVIDED BELOW WILL BE ENTERED UNDER ALL WRAPAROUND MILWAUKEE NETWORK AGENCIES WITH WHICH YOU ARE LISTED AS A PROVIDER.

First Name Last Name
Phone Email Address

Your phone and email address are needed so we may contact you in the event that
we have any questions about the information submitted on this form.

AREA OF PRACTICE:

MENTAL HEALTH SERVICES

Yes No Credential:

(Do not include training credentials)

AGE RANGES SEEN - Selct one or more of the following:
Birth to 3 4-11 12-15 16-18 18-25 25-65 Over 65

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

AODA SERVICES

Yes No Credential:

(Do not include training credentials)

AGE RANGES SEEN - Select one or more of the following:
Birth to 3 4-11 12-15 16-18 18-25 25-65 Over 65

SPECIALITY AREAS (Check the areas that apply to your training and expertise.) Mental Health and AODA issues commonly treated by trained professionals (such as anxiety or anger management) are not listed as specialties.
Specialty	Years Experience	Specialty	Years Experience
ADHD/ADD		Occupational Therapy
Art Therapy		Occ Ther-Sensory Integration
Autism		Panic Disorder
Canine Therapy		Pediatrician
Child Psychiatry		Pet Therapy
Couples Therapy		Physicial Abuse Victim
Divorce		Play Therapy
Domestic Violence		PTSD
Eating Disorders		Reactive Attach Dis
Family Therapy		Recreation Therapy
Gambling Addiction		Sexual Abuse Perpetrator
Gender Identity Issues		Sexual Abuse Victim
Grief/Loss Issues		Teen Pregnancy
HIV/AIDS Related Issues		Terminal Ilness
Music Therapy		Trauma Victim/Witness
Neuro-Psychology Evals
Note: Mental Health and AODA issues commonly treated by trained professionals (such as anxiety or anger management) will not be listed as specalties.
Other - Define	Years Experience	Other Define	Years Experience
LANGUAGES SPOKEN (fluent)
American Sign Language Bosnian Chinese French German Haya Hebrew Hindi Hmong Italian	Japanese Korean Lao Polish Portugese Russian Spanish Swahili Thai Urdu	Language - Other Identify "other" language

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