Skip To Content

TERM Applications

Instructions

Form W-9 (Rev. December 2014)
Request for Taxpayer Identification Number and Certification 2017-11-02
Instructions_and_FAQs_Credentialing_and_Contracting (pdf)
2022-04-05
TERM Panel Specialty Criteria (pdf)
Revised 10/11/2021 2021-10-19

Credentialing Application

1.1 Credentialing Criteria (pdf)
2020-01-30
Credentialing Application Instructions (pdf)
2020-02-26

TERM Therapist Applications

TERM Therapist Clinical Application (docx) Revised 02/01/2023 2023-03-02
Writing Sample Packet for Therapist (pdf) 2024-10-17

TERM Evaluator Applications

TERM Evaluator Application (docx)
2023-04-26
Writing Sample Packet for Evaluators (pdf)
2024-09-12

Interns

Evaluator Intern Packet (docx)
2018-08-29
Therapy Intern Application (docx)
2018-08-29

Specialty Addition Applications

TERM Evaluator Specialty Addition Application (docx)
Revised 02/01/2023 2023-03-02
TERM Therapist Specialty Addition Application (docx)
Revised 02/01/2023 2023-03-02